1528020559 NPI number — KEYSTONE ORTHOPEDIC SPECIALISTS S C

Table of content: (NPI 1528020559)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528020559 NPI number — KEYSTONE ORTHOPEDIC SPECIALISTS S C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEYSTONE ORTHOPEDIC SPECIALISTS 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:
1528020559
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3330 WEST 177TH ST
Provider Second Line Business Mailing Address:
SUITE 2C
Provider Business Mailing Address City Name:
HAZEL CREST
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-799-1144
Provider Business Mailing Address Fax Number:
708-799-4899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3330 WEST 177TH ST
Provider Second Line Business Practice Location Address:
SUITE 2C
Provider Business Practice Location Address City Name:
HAZEL CREST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-799-1144
Provider Business Practice Location Address Fax Number:
708-799-4899
Provider Enumeration Date:
04/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
MARTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
708-799-1144

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208100000X , with the licence number: 036074003 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: CE8619 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CE8620 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000095658 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 01620925 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 367659000 . This is a "DEPT OF LABOR" identifier . This identifiers is of the category "OTHER".




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