Provider Demographics
NPI:1568602480
Name:PREMIER ORTHOPAEDIC AND HAND CENTER, SC
Entity Type:Organization
Organization Name:PREMIER ORTHOPAEDIC AND HAND CENTER, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDI
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-957-0505
Mailing Address - Street 1:19801 GOVERNORS HWY
Mailing Address - Street 2:STE 160
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-7834
Mailing Address - Country:US
Mailing Address - Phone:708-957-0505
Mailing Address - Fax:708-957-0506
Practice Address - Street 1:19801 GOVERNORS HIGHWAY
Practice Address - Street 2:SUITE 160
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-7834
Practice Address - Country:US
Practice Address - Phone:708-957-0505
Practice Address - Fax:708-957-0506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-05
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042619353207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200979570AMedicaid
IL01601075OtherBLUE SHIELD ILLINOIS
ILIL3377Medicare PIN
IN200979570AMedicaid
ILIL3378Medicare PIN
ILIL3379Medicare PIN