Provider Demographics
NPI:1902040124
Name:COMPREHENSIVE ORTHOPEDICS, P. C.
Entity Type:Organization
Organization Name:COMPREHENSIVE ORTHOPEDICS, P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:W
Authorized Official - Last Name:LANE
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:309-692-6644
Mailing Address - Street 1:5401 NORTH KNOXVILLE AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5021
Mailing Address - Country:US
Mailing Address - Phone:309-692-6644
Mailing Address - Fax:309-692-8992
Practice Address - Street 1:5401 NORTH KNOXVILLE AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5021
Practice Address - Country:US
Practice Address - Phone:309-692-6644
Practice Address - Fax:309-692-8992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-01
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060007948174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCH8612OtherRR MEDICARE
IL060007948Medicaid
IL050053OtherHEALTH ALLIANCE
IL7230175OtherBLUE CROSS BLUE SHIELD
IL368270100OtherOWCP DEPARTMENT OF LABORR
IL060007948OtherSTATE LICENSE
IL7230175OtherBLUE CROSS BLUE SHIELD