Provider Demographics
NPI:1609087311
Name:MIDWEST SPORTS MEDICINE & ORTHOPAEDIC SURGICAL SPECIALISTS, LTD.
Entity Type:Organization
Organization Name:MIDWEST SPORTS MEDICINE & ORTHOPAEDIC SURGICAL SPECIALISTS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-437-9889
Mailing Address - Street 1:901 BIESTERFIELD RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3392
Mailing Address - Country:US
Mailing Address - Phone:847-437-9889
Mailing Address - Fax:
Practice Address - Street 1:375 S ROSELLE RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60193-5544
Practice Address - Country:US
Practice Address - Phone:847-437-9889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0526070004Medicare NSC