Provider Demographics
NPI: | 1710908058 |
---|---|
Name: | CENTRAL ILLINOIS ORTHOPEDIC SURGERY S.C. |
Entity Type: | Organization |
Organization Name: | CENTRAL ILLINOIS ORTHOPEDIC SURGERY S.C. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | LAWRENCE |
Authorized Official - Middle Name: | A |
Authorized Official - Last Name: | NORD |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 309-662-2278 |
Mailing Address - Street 1: | 1505 EASTLAND DR |
Mailing Address - Street 2: | SUITE 220 |
Mailing Address - City: | BLOOMINGTON |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 61701-3534 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 309-662-2278 |
Mailing Address - Fax: | 309-663-2956 |
Practice Address - Street 1: | 1505 EASTLAND DR |
Practice Address - Street 2: | SUITE 220 |
Practice Address - City: | BLOOMINGTON |
Practice Address - State: | IL |
Practice Address - Zip Code: | 61701-3534 |
Practice Address - Country: | US |
Practice Address - Phone: | 309-662-2278 |
Practice Address - Fax: | 309-663-2956 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-07-22 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Single Specialty |