Provider Demographics
NPI:1710261623
Name:COMMUNITY ORTHOPEDICS & SPORTS MEDICINE, PC
Entity Type:Organization
Organization Name:COMMUNITY ORTHOPEDICS & SPORTS MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ADDERLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-432-2580
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-0449
Mailing Address - Country:US
Mailing Address - Phone:314-432-2580
Mailing Address - Fax:314-432-0223
Practice Address - Street 1:818 E BROADWAY ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1820
Practice Address - Country:US
Practice Address - Phone:618-443-2177
Practice Address - Fax:618-443-1324
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY ORTHOPEDICS & SPORTS MEDICINE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109093207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL5775Medicare PIN