1831770510 NPI number — MIDWEST SPORTS AND INTERVENTIONAL SPINE SC

Table of content: (NPI 1831770510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831770510 NPI number — MIDWEST SPORTS AND INTERVENTIONAL SPINE SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST SPORTS AND INTERVENTIONAL SPINE 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:
1831770510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2070 GREEN BAY RD STE 163
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGHLAND PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60035-2412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-299-6199
Provider Business Mailing Address Fax Number:
262-293-6953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 GENEVA PARKWAY N
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
LAKE GENEVA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53147-4562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-343-0711
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/15/2021

Additional Information

Authorized Official

Authorized Official Last Name:
PHILIP
Authorized Official First Name:
CYRIL
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
262-299-6199

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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