Provider Demographics
NPI:1225473952
Name:ORTHOPEDIC & SPINE SURGERY ASSOC LTD
Entity Type:Organization
Organization Name:ORTHOPEDIC & SPINE SURGERY ASSOC LTD
Other - Org Name:MIDWEST BONE & JOINT INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALLENIUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-931-5300
Mailing Address - Street 1:2350 ROYAL BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-4719
Mailing Address - Country:US
Mailing Address - Phone:847-931-5300
Mailing Address - Fax:847-931-5321
Practice Address - Street 1:1710 N RANDALL RD
Practice Address - Street 2:SUITE 140
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-9400
Practice Address - Country:US
Practice Address - Phone:224-293-1170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies