1437453073 NPI number — ORTHOPEDIC & SHOULDER CENTER, S.C.

Table of content: (NPI 1437453073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437453073 NPI number — ORTHOPEDIC & SHOULDER CENTER, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOPEDIC & SHOULDER CENTER, S.C.
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:
Provider Other Organization Name Type Code:
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:
1437453073
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 FORT JESSE ROAD
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
NORMAL
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-888-9800
Provider Business Mailing Address Fax Number:
309-828-9700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 FORT JESSE RD STE 250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORMAL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61761-6290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-454-1616
Provider Business Practice Location Address Fax Number:
309-454-5167
Provider Enumeration Date:
12/22/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MEISNER
Authorized Official First Name:
BRANDI
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
309-888-9800

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  036092458 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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