Basic Information
| Provider Information | |||||||||
| NPI: | 1578772927 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDWEST SPORTS MEDICINE & ORTHOPEDIC SURGICAL SPECIALISTS | ||||||||
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| OtherOrganizationName: | THE CENTER FOR PAIN MANAGEMENT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 BIESTERFIELD RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600073392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474379889 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 BIESTERFIELD RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600073392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474379889 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | ROSEMARY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8474379889 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 31603457 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |