Provider Demographics
NPI:1609990944
Name:REGIONAL ORTHOPAEDICS & SPORTS MEDICINE CENTER, LTD.
Entity Type:Organization
Organization Name:REGIONAL ORTHOPAEDICS & SPORTS MEDICINE CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARR
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-243-0033
Mailing Address - Street 1:1600 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1136
Mailing Address - Country:US
Mailing Address - Phone:217-243-0033
Mailing Address - Fax:217-245-1791
Practice Address - Street 1:1600 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1136
Practice Address - Country:US
Practice Address - Phone:217-243-0033
Practice Address - Fax:217-245-1791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088511207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088511Medicaid
ILF51912Medicare UPIN
IL214806Medicare PIN
IL036088511Medicaid
IL346070Medicare ID - Type Unspecified