1710088703 NPI number — OSTEOPATHIC SPORTS MEDICINE, S.C.

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 1710088703 NPI number — OSTEOPATHIC SPORTS MEDICINE, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OSTEOPATHIC SPORTS MEDICINE, 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:
6
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:
1710088703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6715 KINGERY HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLOWBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60527-5142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-455-0212
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6715 KINGERY HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLOWBROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60527-5142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-455-0212
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HEINKING
Authorized Official First Name:
KURT
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
630-455-0212

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04922838 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 04922838 . This is a "BLUE SHIELD PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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