Provider Demographics
NPI:1760457204
Name:ORTHOPAEDIC SURGERY CENTER OF ILLINOIS, LLC
Entity Type:Organization
Organization Name:ORTHOPAEDIC SURGERY CENTER OF ILLINOIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:217-862-0500
Mailing Address - Street 1:3136 OLD JACKSONVILLE RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6487
Mailing Address - Country:US
Mailing Address - Phone:217-862-0500
Mailing Address - Fax:
Practice Address - Street 1:3136 OLD JACKSONVILLE RD
Practice Address - Street 2:SUITE 250
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6487
Practice Address - Country:US
Practice Address - Phone:217-862-0500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-20
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002306261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL490004938OtherRR MEDICARE
IL007002306Medicaid
IL007002306Medicaid