Provider Demographics
NPI:1447421086
Name:KEYSTONE ORTHOPEDICS S.C.
Entity Type:Organization
Organization Name:KEYSTONE ORTHOPEDICS S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:HERTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-799-1144
Mailing Address - Street 1:3330 W 177TH ST
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-2184
Mailing Address - Country:US
Mailing Address - Phone:708-799-1144
Mailing Address - Fax:708-799-4899
Practice Address - Street 1:801 MACARTHUR BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2915
Practice Address - Country:US
Practice Address - Phone:219-836-4123
Practice Address - Fax:219-836-0276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036580A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1023490002Medicare NSC