Provider Demographics
NPI:1710088703
Name:OSTEOPATHIC SPORTS MEDICINE, S.C.
Entity Type:Organization
Organization Name:OSTEOPATHIC SPORTS MEDICINE, S.C.
Other - Org Name:CHICAGO OSTEOPATHIC HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:P
Authorized Official - Last Name:HEINKING
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:630-455-0212
Mailing Address - Street 1:6715 KINGERY HWY
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5142
Mailing Address - Country:US
Mailing Address - Phone:630-455-0212
Mailing Address - Fax:
Practice Address - Street 1:6715 KINGERY HWY
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5142
Practice Address - Country:US
Practice Address - Phone:630-455-0212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04922838OtherBLUE CROSS BLUE SHIELD
IL04922838OtherBLUE SHIELD PROVIDER #
IL04922838OtherBLUE CROSS BLUE SHIELD
ILK25434Medicare PIN