Provider Demographics
NPI:1043522451
Name:AFFILIATED ORTHOPEDIC SERVICES LTD
Entity Type:Organization
Organization Name:AFFILIATED ORTHOPEDIC SERVICES LTD
Other - Org Name:LAKE COUNTY ORTHOPEDIC AND SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FETTER
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:847-599-9200
Mailing Address - Street 1:135 N GREENLEAF ST STE 126
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3334
Mailing Address - Country:US
Mailing Address - Phone:847-599-9200
Mailing Address - Fax:
Practice Address - Street 1:135 N GREENLEAF ST STE 126
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3334
Practice Address - Country:US
Practice Address - Phone:847-599-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-14
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03604536Medicaid
WI34444000Medicaid
ILC38256Medicare UPIN
WI34444000Medicaid
IL03604536Medicaid