Provider Demographics
NPI:1861672677
Name:GRANITE CITY ORTHOPEDIC PHYSICIANS COMPANY LLC
Entity Type:Organization
Organization Name:GRANITE CITY ORTHOPEDIC PHYSICIANS COMPANY LLC
Other - Org Name:ILLINOIS SW ORTHOPEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. DIRECTOR PHYSICIAN REV CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:FEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-221-3641
Mailing Address - Street 1:4802 S STATE ROUTE 159
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1904
Mailing Address - Country:US
Mailing Address - Phone:618-288-4388
Mailing Address - Fax:618-288-4927
Practice Address - Street 1:4802 S STATE ROUTE 159
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1904
Practice Address - Country:US
Practice Address - Phone:618-288-4388
Practice Address - Fax:618-288-4927
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANITE CITY ORTHOPEDIC PHYSICIANS COMPANY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-08
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6032134OtherBCBS GROUP #
MO504042508Medicaid
IL6032134OtherBCBS GROUP #
IL6014850001Medicare NSC
MO504042508Medicaid