Provider Demographics
NPI:1619422516
Name:ORTHOMIDWEST, PLLC
Entity Type:Organization
Organization Name:ORTHOMIDWEST, PLLC
Other - Org Name:ORTHOILLINOIS
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELMER
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:815-381-7431
Mailing Address - Street 1:PO BOX 735263
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5263
Mailing Address - Country:US
Mailing Address - Phone:815-398-9491
Mailing Address - Fax:815-381-7333
Practice Address - Street 1:5875 E RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-4937
Practice Address - Country:US
Practice Address - Phone:815-398-9491
Practice Address - Fax:815-381-7333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-20
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060010826332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies