1568602480 NPI number — PREMIER ORTHOPAEDIC AND HAND CENTER, SC

Table of content: (NPI 1568602480)

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".




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