Provider Demographics
NPI:1134361645
Name:MIDWEST ORTHOPEDIC SERVICES, SC
Entity type:Organization
Organization Name:MIDWEST ORTHOPEDIC SERVICES, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-341-1301
Mailing Address - Street 1:834 N SEMINARY ST
Mailing Address - Street 2:SUITE 406
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2852
Mailing Address - Country:US
Mailing Address - Phone:309-341-1301
Mailing Address - Fax:309-341-1377
Practice Address - Street 1:834 N SEMINARY ST
Practice Address - Street 2:SUITE 406
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2852
Practice Address - Country:US
Practice Address - Phone:309-341-1301
Practice Address - Fax:309-341-1377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-052254207X00000X
IL016-004267213ES0131X
IL036-049846207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5725610001OtherMEDICARE DMEPOS# / ADMINSTAR FEDERAL
IL5725610001OtherMEDICARE DMEPOS# / ADMINSTAR FEDERAL