Provider Demographics
NPI:1578971487
Name:NORTHERN ILLINOIS TRAUMA REGIONAL ORTHOPAEDICS, LLC
Entity Type:Organization
Organization Name:NORTHERN ILLINOIS TRAUMA REGIONAL ORTHOPAEDICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLINT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-636-0700
Mailing Address - Street 1:1235 N MULFORD RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3879
Mailing Address - Country:US
Mailing Address - Phone:815-636-0700
Mailing Address - Fax:815-904-6033
Practice Address - Street 1:1235 N MULFORD RD
Practice Address - Street 2:SUITE 103
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3879
Practice Address - Country:US
Practice Address - Phone:815-636-0700
Practice Address - Fax:815-904-6033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-24
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic TraumaGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF100170041Medicaid