Provider Demographics
NPI:1801005376
Name:MIDWEST SPORTS MEDICINE & ORTHOPEDIC SURGICAL SPECIALIST LTD
Entity Type:Organization
Organization Name:MIDWEST SPORTS MEDICINE & ORTHOPEDIC SURGICAL SPECIALIST LTD
Other - Org Name:OPEN MRI IMAGING SPECIALISTS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-437-9889
Mailing Address - Street 1:PO BOX 807
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60009-0807
Mailing Address - Country:US
Mailing Address - Phone:847-437-9889
Mailing Address - Fax:
Practice Address - Street 1:901 W BIESTERFIELD ROAD
Practice Address - Street 2:SUITE 306
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-7324
Practice Address - Country:US
Practice Address - Phone:847-437-9889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31603457OtherBCBS
IL200006961OtherMEDICARE RAILROAD
IL31603457OtherBCBS
ILK19416Medicare PIN
IL200006961OtherMEDICARE RAILROAD