Provider Demographics
NPI:1801859442
Name:ORTHOPEDIC ASSOCIATES OF PEORIA, S.C.
Entity Type:Organization
Organization Name:ORTHOPEDIC ASSOCIATES OF PEORIA, S.C.
Other - Org Name:D/B/A GREAT PLAINS ORTHOPAEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-676-5546
Mailing Address - Street 1:303 N WILLIAM KUMPF BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-2507
Mailing Address - Country:US
Mailing Address - Phone:309-676-5546
Mailing Address - Fax:309-676-5045
Practice Address - Street 1:303 N WILLIAM KUMPF BLVD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-2507
Practice Address - Country:US
Practice Address - Phone:309-676-5546
Practice Address - Fax:309-676-5045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042000244207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1467418350Medicare NSC
IL767220Medicare PIN