Provider Demographics
NPI:1669681011
Name:MIDWEST SPORTS MEDICINE & ORTHOPEDIC SURGICAL SPECIALISTS, LTD
Entity Type:Organization
Organization Name:MIDWEST SPORTS MEDICINE & ORTHOPEDIC SURGICAL SPECIALISTS, LTD
Other - Org Name:THE CENTER FOR PHYSCIAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
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 306
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3392
Mailing Address - Country:US
Mailing Address - Phone:847-437-1230
Mailing Address - Fax:847-944-1240
Practice Address - Street 1:901 BIESTERFIELD RD
Practice Address - Street 2:SUITE 306
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3392
Practice Address - Country:US
Practice Address - Phone:847-437-1230
Practice Address - Fax:847-944-1240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31603457OtherBLUE CROSS BLUE SHIELD
IL212020Medicare ID - Type Unspecified