Provider Demographics
NPI:1346389061
Name:GENESIS ORTHOPEDICS & SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:GENESIS ORTHOPEDICS & SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HYTHEM
Authorized Official - Middle Name:P
Authorized Official - Last Name:SHADID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-377-1188
Mailing Address - Street 1:2900 FOXFIELD RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5799
Mailing Address - Country:US
Mailing Address - Phone:630-377-1188
Mailing Address - Fax:630-377-7360
Practice Address - Street 1:2900 FOXFIELD RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5799
Practice Address - Country:US
Practice Address - Phone:630-377-1188
Practice Address - Fax:630-377-7360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082388207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1205885001OtherLESNIEWSKI NPI
IL036082388Medicaid
IL1477567394OtherSHADID NPI
ILDO4326OtherGROUP PTAN
IL04525539OtherBCBS
IL036082388Medicaid
ILDO4326OtherGROUP PTAN
ILDO4326OtherGROUP PTAN
IL1205885001OtherLESNIEWSKI NPI
IL036082388Medicaid