Basic Information
| Provider Information | |||||||||
| NPI: | 1801005376 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST SPORTS MEDICINE & ORTHOPEDIC SURGICAL SPECIALIST LTD | ||||||||
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| OtherOrganizationName: | OPEN MRI IMAGING SPECIALISTS, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 807 | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600090807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474379889 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 W BIESTERFIELD ROAD | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600077324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474379889 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | ROSEMARY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8474379889 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 200006961 | 01 | IL | MEDICARE RAILROAD | OTHER |