Provider Demographics
NPI:1144220724
Name:MIDWEST SPORTS MEDICINE & ORTHOPAEDIC SURGICAL SPECIALISTS, LTD.
Entity Type:Organization
Organization Name:MIDWEST SPORTS MEDICINE & ORTHOPAEDIC SURGICAL SPECIALISTS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDRAZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-437-9889
Mailing Address - Street 1:901 BIESTERFIELD RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3392
Mailing Address - Country:US
Mailing Address - Phone:847-437-9889
Mailing Address - Fax:847-437-4149
Practice Address - Street 1:901 BIESTERFIELD RD
Practice Address - Street 2:SUITE 300
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3392
Practice Address - Country:US
Practice Address - Phone:847-437-9889
Practice Address - Fax:847-437-4149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-006737207XX0005X
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31603457OtherBC/BS
IL212020Medicare PIN
IL31603457OtherBC/BS
ILK19420Medicare PIN
ILK19416Medicare PIN
ILK19415Medicare PIN
ILK19417Medicare PIN
IL0526070001Medicare NSC
IL0526070002Medicare NSC
ILK29886Medicare PIN
ILK32159Medicare PIN