Provider Demographics
NPI:1033128483
Name:ACCIDENT & SPORTS CLINIC SC
Entity Type:Organization
Organization Name:ACCIDENT & SPORTS CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FITTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-664-6040
Mailing Address - Street 1:3901 GENERAL ELECTRIC RD
Mailing Address - Street 2:#2
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8746
Mailing Address - Country:US
Mailing Address - Phone:309-664-6040
Mailing Address - Fax:309-664-6121
Practice Address - Street 1:3901 GENERAL ELECTRIC RD
Practice Address - Street 2:#2
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8746
Practice Address - Country:US
Practice Address - Phone:309-664-6040
Practice Address - Fax:309-664-6121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038005760Medicaid
IL350036554OtherRAILROAD MEDICARE
IL005782025OtherBLUE CROSS/BLUE SHIELD
ILT92518Medicare UPIN
IL212678Medicare PIN