1861772261 NPI number — MIDWEST BONE & JOINT SURGERY

Table of content: (NPI 1861772261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861772261 NPI number — MIDWEST BONE & JOINT SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST BONE & JOINT SURGERY
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:
1861772261
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 APEX DR
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
HIGHLAND
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62249-1285
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-654-5400
Provider Business Mailing Address Fax Number:
618-654-8787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11155 DUNN RD
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63136-6150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-654-5400
Provider Business Practice Location Address Fax Number:
618-654-8787
Provider Enumeration Date:
08/17/2011

Additional Information

Authorized Official

Authorized Official Last Name:
UNGACTA
Authorized Official First Name:
FELIX
Authorized Official Middle Name:
Authorized Official Title or Position:
ORTHOPEDIC SURGEON
Authorized Official Telephone Number:
618-541-1406

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  106268 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 215632 . This is a "MEDICARE GROUP PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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