Provider Demographics
NPI:1558496265
Name:WESTERN ILLINOIS SPORTS MEDICINE AND ORTHOPEDIC CENTER
Entity Type:Organization
Organization Name:WESTERN ILLINOIS SPORTS MEDICINE AND ORTHOPEDIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-224-8955
Mailing Address - Street 1:927 BROADWAY ST STE 104
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2728
Mailing Address - Country:US
Mailing Address - Phone:217-224-8955
Mailing Address - Fax:217-223-8917
Practice Address - Street 1:927 BROADWAY ST STE 104
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2728
Practice Address - Country:US
Practice Address - Phone:217-224-8955
Practice Address - Fax:217-223-8917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
212896Medicare ID - Type Unspecified
A44601Medicare UPIN