Basic Information
| Provider Information | |||||||||
| NPI: | 1366534083 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDIC & SPORTS MEDICINE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 FORT JESSE RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617616290 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 2200 FORT JESSE RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617616290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094541616 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 11/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | CHADWICK | ||||||||
| AuthorizedOfficialFirstName: | GREGG | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3094541616 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 042-616684 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.