Provider Demographics
NPI:1710199906
Name:ADVANCED ORTHOPEDIC & SPORTS INJURY CENTER, LTD.
Entity Type:Organization
Organization Name:ADVANCED ORTHOPEDIC & SPORTS INJURY CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:FETTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-599-9500
Mailing Address - Street 1:2626 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085
Mailing Address - Country:US
Mailing Address - Phone:847-599-9500
Mailing Address - Fax:847-599-9485
Practice Address - Street 1:2626 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085
Practice Address - Country:US
Practice Address - Phone:847-599-9500
Practice Address - Fax:847-599-9485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC43737Medicare UPIN
IL225340Medicare ID - Type Unspecified