Provider Demographics
NPI:1639299712
Name:WESTGATE ORTHOPAEDICS, LTD.
Entity Type:Organization
Organization Name:WESTGATE ORTHOPAEDICS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:BOONE
Authorized Official - Last Name:BRACKETT
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:708-848-7700
Mailing Address - Street 1:1125 WESTGATE ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1007
Mailing Address - Country:US
Mailing Address - Phone:708-848-7700
Mailing Address - Fax:708-848-9375
Practice Address - Street 1:1125 WESTGATE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1007
Practice Address - Country:US
Practice Address - Phone:708-848-7700
Practice Address - Fax:708-848-9375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-37881207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036037881Medicaid
452390Medicare ID - Type Unspecified
IL036037881Medicaid
IL0579120001Medicare NSC