Basic Information
| Provider Information | |||||||||
| NPI: | 1083817407 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR ATHLETIC MEDICINE LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 830 W DIVERSEY PKWY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606141454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732484150 | ||||||||
| FaxNumber: | 7732484291 | ||||||||
| Practice Location | |||||||||
| Address1: | 830 W DIVERSEY PKWY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606141454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732484150 | ||||||||
| FaxNumber: | 7732484291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 07/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | WOLIN | ||||||||
| AuthorizedOfficialFirstName: | PRESTON | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 7732484150 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 36060229 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.