Provider Demographics
NPI:1306835491
Name:ORCHARD MEDICAL CENTER SC
Entity Type:Organization
Organization Name:ORCHARD MEDICAL CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-395-3322
Mailing Address - Street 1:543 ORCHARD ST ORCHARD MEDICAL CENTER SC
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-3107
Mailing Address - Country:US
Mailing Address - Phone:847-395-3322
Mailing Address - Fax:847-395-0921
Practice Address - Street 1:543 ORCHARD ST
Practice Address - Street 2:ORCHARD MEDICAL CENTER SC
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-3107
Practice Address - Country:US
Practice Address - Phone:847-395-3322
Practice Address - Fax:847-395-0921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL637760Medicaid
IL637760Medicare ID - Type Unspecified