Provider Demographics
NPI:1588847446
Name:THE CENTER FOR ADVANCED ORTHOPEDICS, LLC
Entity Type:Organization
Organization Name:THE CENTER FOR ADVANCED ORTHOPEDICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIERNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-288-9460
Mailing Address - Street 1:6812 STATE ROUTE 162
Mailing Address - Street 2:123
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062
Mailing Address - Country:US
Mailing Address - Phone:618-288-9460
Mailing Address - Fax:
Practice Address - Street 1:6812 STATE RTE 162
Practice Address - Street 2:123
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8500
Practice Address - Country:US
Practice Address - Phone:618-288-9460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110043003Medicaid
IL036110043003Medicaid
IL6034200001Medicare NSC