Basic Information
| Provider Information | |||||||||
| NPI: | 1104330034 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HINSDALE ORTHOPAEDIC ASSOCIATES, S.C. | ||||||||
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| OtherOrganizationName: | HINSDALE ORTHOPAEDIC ASSOCIATES, S.C., P.C. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 W OGDEN AVE | ||||||||
| Address2: | ATTN MARY ALICE RADFORD | ||||||||
| City: | HINSDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605213186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307948671 | ||||||||
| FaxNumber: | 6307948629 | ||||||||
| Practice Location | |||||||||
| Address1: | 8141 S CALUMET AVE | ||||||||
| Address2: | UNIT 1 | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303236116 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2017 | ||||||||
| LastUpdateDate: | 11/30/2017 | ||||||||
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| AuthorizedOfficialLastName: | RADFORD | ||||||||
| AuthorizedOfficialFirstName: | MARY ALICE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6307948671 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HINSDALE ORTHOPAEDIC ASSOCIATES, S.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 50005393A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 500005393A | 01 | IN | MEDICAL CORPORATION LICENSE | OTHER |