Provider Demographics
NPI:1679503692
Name:THE CENTER FOR ORTHOPEDIC MEDICINE, LLC
Entity Type:Organization
Organization Name:THE CENTER FOR ORTHOPEDIC MEDICINE, LLC
Other - Org Name:THE CENTER FOR OUTPATIENT MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-662-6120
Mailing Address - Street 1:2502 B. EAST EMPIRE STREET
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704
Mailing Address - Country:US
Mailing Address - Phone:309-662-6120
Mailing Address - Fax:309-661-0060
Practice Address - Street 1:2502 B. EAST EMPIRE STREET
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704
Practice Address - Country:US
Practice Address - Phone:309-662-6120
Practice Address - Fax:309-661-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002116261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001937OtherHEALTH ALLIANCE
IL00214363001OtherUNITED HEALTHCARE
IL551OtherBLUE CROSS BLUE SHEILD
IL490003202OtherRR MEDICARE
IL=========001Medicaid