Provider Demographics
NPI:1942379110
Name:ORTHO-SPORT, INC.
Entity Type:Organization
Organization Name:ORTHO-SPORT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:KEENUM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:708-366-2442
Mailing Address - Street 1:800 DES PLAINES AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-2035
Mailing Address - Country:US
Mailing Address - Phone:708-366-2442
Mailing Address - Fax:708-366-0179
Practice Address - Street 1:800 DES PLAINES AVE
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2035
Practice Address - Country:US
Practice Address - Phone:708-366-2442
Practice Address - Fax:708-366-0179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1683317OtherBCBS OF IL
IL592100Medicare ID - Type UnspecifiedDUPAGE WILL KANE
ILDD5558Medicare ID - Type UnspecifiedMEDICARE RR
IL1683317OtherBCBS OF IL