Provider Demographics
NPI:1134171226
Name:ORTHOPAEDIC CENTER OF SOUTHERN ILLINOIS, LTD.
Entity type:Organization
Organization Name:ORTHOPAEDIC CENTER OF SOUTHERN ILLINOIS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN BENOIT
Authorized Official - Middle Name:
Authorized Official - Last Name:HOULE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-242-3778
Mailing Address - Street 1:4121 VETERANS MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6262
Mailing Address - Country:US
Mailing Address - Phone:618-242-3778
Mailing Address - Fax:618-242-2551
Practice Address - Street 1:4121 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6262
Practice Address - Country:US
Practice Address - Phone:618-242-3778
Practice Address - Fax:618-242-2551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097382207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0991060001Medicare NSC
IL456840Medicare PIN