1255622163 NPI number — GROSSKOPF ORTHOPEDIC SC

Table of content: (NPI 1255622163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255622163 NPI number — GROSSKOPF ORTHOPEDIC SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GROSSKOPF ORTHOPEDIC 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:
1255622163
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3805 E MAIN ST
Provider Second Line Business Mailing Address:
SUITE G
Provider Business Mailing Address City Name:
SAINT CHARLES
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60174-2487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-402-2128
Provider Business Mailing Address Fax Number:
630-397-7814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3805 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
SAINT CHARLES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60174-2487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-402-2128
Provider Business Practice Location Address Fax Number:
630-397-7814
Provider Enumeration Date:
04/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GROSSKOPF
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
630-402-2128

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  036066604 , 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: C44349 . This is a "UPIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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