Provider Demographics
NPI:1972621969
Name:MIDWAY DISC AND SPINE CENTER
Entity Type:Organization
Organization Name:MIDWAY DISC AND SPINE CENTER
Other - Org Name:OSTEORTHRITIS CENTER OF FOREST PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-767-2225
Mailing Address - Street 1:6457 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-5148
Mailing Address - Country:US
Mailing Address - Phone:773-767-2225
Mailing Address - Fax:
Practice Address - Street 1:6457 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5148
Practice Address - Country:US
Practice Address - Phone:773-767-2225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216314Medicare PIN
IL6489670001Medicare NSC