Provider Demographics
NPI:1992220404
Name:CHICAGO SPORTS MEDICINE INSTITUTE
Entity Type:Organization
Organization Name:CHICAGO SPORTS MEDICINE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-480-4584
Mailing Address - Street 1:875 N DEARBORN ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-7377
Mailing Address - Country:US
Mailing Address - Phone:312-255-7540
Mailing Address - Fax:312-255-1276
Practice Address - Street 1:875 N DEARBORN ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-7377
Practice Address - Country:US
Practice Address - Phone:312-255-7540
Practice Address - Fax:312-255-1276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091945OtherLICENSE