1144205600 NPI number — MIDWEST MINIMALLY INVASIVE SPINE SPECIALISTS SC

Table of content: (NPI 1144205600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144205600 NPI number — MIDWEST MINIMALLY INVASIVE SPINE SPECIALISTS SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST MINIMALLY INVASIVE SPINE SPECIALISTS SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MINIMALLY INVASIVE SPINE SPECIALIST SC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144205600
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4037
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60507-4037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-390-2290
Provider Business Mailing Address Fax Number:
708-390-2299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19110 DARVIN DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
MOKENA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60448-8595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-390-2290
Provider Business Practice Location Address Fax Number:
708-390-2299
Provider Enumeration Date:
12/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SWEENEY
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
708-390-2290

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  042617626 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: 50004759A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XS0117X , with the licence number: 042617626 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XS0117X , with the licence number: 50004759A , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DO9194 . This is a "RR MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 01632167 . This is a "BC/BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: CK7919 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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