Basic Information
Provider Information | |||||||||
NPI: | 1356551964 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MIDWEST SPORTS MEDICINE & ORTHOPAEDIC SURGICAL SPECIALISTS, LTD. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OPEN MRI IMAGING SPECIALISTS, LLC. | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 807 | ||||||||
Address2: |   | ||||||||
City: | ELK GROVE VILLAGE | ||||||||
State: | IL | ||||||||
PostalCode: | 600090807 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8474379889 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 375 S ROSELLE RD | ||||||||
Address2: |   | ||||||||
City: | SCHAUMBURG | ||||||||
State: | IL | ||||||||
PostalCode: | 601935544 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8474379889 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2007 | ||||||||
LastUpdateDate: | 05/27/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARTIN | ||||||||
AuthorizedOfficialFirstName: | ROSEMARY | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 8474379889 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
ID | Type | State | Issuer | Description | 31603457 | 01 | IL | BCBS | OTHER |