1205374717 NPI number — WHEATON ORTHOPAEDICS, LTD

Table of content: (NPI 1205374717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205374717 NPI number — WHEATON ORTHOPAEDICS, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHEATON ORTHOPAEDICS, LTD
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:
SPORTSMED-WHEATON ORTHOPAEDICS
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:
1205374717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
327 GUNDERSEN DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
CAROL STREAM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60188-2402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-665-9155
Provider Business Mailing Address Fax Number:
630-665-9770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1971 GOWDEY RD
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
NAPERVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60563-4232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-665-9155
Provider Business Practice Location Address Fax Number:
630-665-9770
Provider Enumeration Date:
02/03/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BAKER
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
630-665-9155

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  042001705 , 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: 0002215428 . This is a "BLUE CROSS BLUE SHIELD OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 130944200 . This is a "US DEPARTMENT OF LABOR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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