1568602480 NPI number — PREMIER ORTHOPAEDIC AND HAND CENTER, SC

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 1568602480 NPI number — PREMIER ORTHOPAEDIC AND HAND CENTER, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER ORTHOPAEDIC AND HAND CENTER, 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:
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:
1568602480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19801 GOVERNORS HWY
Provider Second Line Business Mailing Address:
STE 160
Provider Business Mailing Address City Name:
FLOSSMOOR
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60422-7834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-957-0505
Provider Business Mailing Address Fax Number:
708-957-0506

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19801 GOVERNORS HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
FLOSSMOOR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60422-7834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-957-0505
Provider Business Practice Location Address Fax Number:
708-957-0506
Provider Enumeration Date:
03/05/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JEFFERS
Authorized Official First Name:
WENDI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
708-957-0505

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  042619353 , 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)

  • Identifier: 200979570A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01601075 . This is a "BLUE SHIELD ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".