1518101690 NPI number — MIDWEST BONE & JOINT SURGERY PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518101690 NPI number — MIDWEST BONE & JOINT SURGERY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST BONE & JOINT SURGERY PC
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:
1518101690
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 APEX DR
Provider Second Line Business Mailing Address:
SUITE #1
Provider Business Mailing Address City Name:
HIGHLAND
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62249-1285
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-654-5400
Provider Business Mailing Address Fax Number:
618-654-8787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 DES PERES RD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63131-2050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-654-5400
Provider Business Practice Location Address Fax Number:
618-654-8787
Provider Enumeration Date:
04/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
UNGACTA
Authorized Official First Name:
FELIX
Authorized Official Middle Name:
F
Authorized Official Title or Position:
ORTHOPEDIC SURGEON
Authorized Official Telephone Number:
618-541-1406

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  106268 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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