Provider Demographics
NPI:1275618480
Name:BELLEVILLE ORTHOPEDICS, P.C.
Entity Type:Organization
Organization Name:BELLEVILLE ORTHOPEDICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MIRLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-235-2900
Mailing Address - Street 1:4550 MEMORIAL DR
Mailing Address - Street 2:SUITE 460
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5359
Mailing Address - Country:US
Mailing Address - Phone:618-235-2900
Mailing Address - Fax:618-235-2902
Practice Address - Street 1:4550 MEMORIAL DR
Practice Address - Street 2:SUITE 460
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5359
Practice Address - Country:US
Practice Address - Phone:618-235-2900
Practice Address - Fax:618-235-2902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085921174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210163Medicare ID - Type UnspecifiedGROUP NUMBER
IL5302320001Medicare NSC