Provider Demographics
NPI:1114171477
Name:CHICAGO ORTHOPAEDICS AND SPORTS MEDICINE, S.C.
Entity Type:Organization
Organization Name:CHICAGO ORTHOPAEDICS AND SPORTS MEDICINE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-433-3130
Mailing Address - Street 1:3000 N HALSTED ST
Mailing Address - Street 2:#525
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5188
Mailing Address - Country:US
Mailing Address - Phone:773-433-3130
Mailing Address - Fax:773-433-3125
Practice Address - Street 1:3000 N HALSTED ST
Practice Address - Street 2:#525
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5188
Practice Address - Country:US
Practice Address - Phone:773-433-3130
Practice Address - Fax:773-433-3125
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHICAGO ORTHOPAEDICS AND SPORTS MEDICINE, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-12
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-070934174400000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0864364Medicaid
IL206304Medicare PIN