Provider Demographics
| NPI: | 1962481861 |
|---|---|
| Name: | ORA ORTHOPEDICS PC |
| Entity Type: | Organization |
| Organization Name: | ORA ORTHOPEDICS PC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CEO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | KENNETH |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | BROCKMAN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 309-762-3621 |
| Mailing Address - Street 1: | 520 VALLEY VIEW DR |
| Mailing Address - Street 2: | |
| Mailing Address - City: | MOLINE |
| Mailing Address - State: | IL |
| Mailing Address - Zip Code: | 61265-6194 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 309-762-3621 |
| Mailing Address - Fax: | 309-762-3690 |
| Practice Address - Street 1: | 520 VALLEY VIEW DR |
| Practice Address - Street 2: | |
| Practice Address - City: | MOLINE |
| Practice Address - State: | IL |
| Practice Address - Zip Code: | 61265-6194 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 309-762-3621 |
| Practice Address - Fax: | 309-762-3690 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | ORA ORTHOPEDICS PC |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2006-01-10 |
| Last Update Date: | 2012-08-24 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 163WM0705X, 207QS0010X, 207RR0500X, 207XS0106X, 2084N0400X, 2084N0600X, 213ES0103X, 246ZS0410X, 247200000X, 332B00000X, 335E00000X, 363AM0700X, 363AS0400X, 363L00000X | ||
| IL | 060006850 | 207X00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 163WM0705X | Nursing Service Providers | Registered Nurse | Medical-Surgical | Group - Multi-Specialty |
| No | 207QS0010X | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | Group - Multi-Specialty |
| No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
| No | 207XS0106X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | Group - Multi-Specialty |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 2084N0600X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | Group - Multi-Specialty |
| No | 213ES0103X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | Group - Multi-Specialty |
| No | 246ZS0410X | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Surgical Technologist | Group - Multi-Specialty |
| No | 247200000X | Technologists, Technicians & Other Technical Service Providers | Technician, Other | Group - Multi-Specialty | |
| No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | ||
| No | 335E00000X | Suppliers | Prosthetic/Orthotic Supplier | Group - Multi-Specialty | |
| No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
| No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Multi-Specialty |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| IA | 58091 | Other | WELLMARK |
| IA | 58109 | Other | WELLMARK |
| IA | 92231 | Other | WELLMARK |
| ID | CN0248 | Other | RR MEDICARE |
| IA | 58104 | Other | WELLMARK |
| IA | 57821 | Other | WELLMARK |
| IA | 99204 | Other | WELLMARK |
| IA | 0073734 | Medicaid | |
| IA | CD9661 | Other | RR MEDICARE |
| IA | 37772 | Other | WELLMARK |
| IL | 8121085 | Other | BCBS-IL |
| IA | 91376 | Other | WELLMARK |
| IA | 91376 | Other | WELLMARK |
| IL | 8121085 | Other | BCBS-IL |
| IA | 57821 | Medicare ID - Type Unspecified | |
| IA | 92231 | Other | WELLMARK |
| IA | 58091 | Medicare ID - Type Unspecified |
