Basic Information
| Provider Information | |||||||||
| NPI: | 1144220724 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST SPORTS MEDICINE & ORTHOPAEDIC SURGICAL SPECIALISTS, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 BIESTERFIELD RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600073392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474379889 | ||||||||
| FaxNumber: | 8474374149 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 BIESTERFIELD RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600073392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474379889 | ||||||||
| FaxNumber: | 8474374149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | ROSEMARY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8474379889 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207XX0005X | 042-006737 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31603457 | 01 | IL | BC/BS | OTHER |