Provider Demographics
NPI:1528020559
Name:KEYSTONE ORTHOPEDIC SPECIALISTS S C
Entity Type:Organization
Organization Name:KEYSTONE ORTHOPEDIC SPECIALISTS S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-799-1144
Mailing Address - Street 1:3330 WEST 177TH ST
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429
Mailing Address - Country:US
Mailing Address - Phone:708-799-1144
Mailing Address - Fax:708-799-4899
Practice Address - Street 1:3330 WEST 177TH ST
Practice Address - Street 2:SUITE 2C
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429
Practice Address - Country:US
Practice Address - Phone:708-799-1144
Practice Address - Fax:708-799-4899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207L00000X, 207X00000X, 213E00000X, 363AS0400X
IL036074003208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCE8619OtherRAILROAD MEDICARE
INCE8620OtherRAILROAD MEDICARE
IN000000095658OtherBCBS
IL01620925OtherBCBS
367659000OtherDEPT OF LABOR
IN1023490002Medicare NSC
IL1023490001Medicare NSC
IL01620925OtherBCBS
IN000000095658OtherBCBS