Provider Demographics
NPI:1033364534
Name:WHEATON ORTHOPAEDICS, LTD.
Entity Type:Organization
Organization Name:WHEATON ORTHOPAEDICS, LTD.
Other - Org Name:SPORTSMED WHEATON ORTHOPAEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAMIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-784-3295
Mailing Address - Street 1:327 GUNDERSEN DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-2402
Mailing Address - Country:US
Mailing Address - Phone:630-665-9155
Mailing Address - Fax:630-665-5557
Practice Address - Street 1:327 GUNDERSEN DR
Practice Address - Street 2:SUITE A
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-2402
Practice Address - Country:US
Practice Address - Phone:630-665-9155
Practice Address - Fax:630-665-5557
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHEATON ORTHOPAEDICS, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041162131163W00000X
IL041261134163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02233497OtherBLUE CROSS BLUE SHIELD OF ILLINOIS