Provider Demographics
NPI:1295753093
Name:CARLOS ORTEGA MD SC
Entity type:Organization
Organization Name:CARLOS ORTEGA MD SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:D
Authorized Official - Last Name:ORTEGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-235-8887
Mailing Address - Street 1:5140 N CALIFORNIA AVE STE 780
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-7066
Mailing Address - Country:US
Mailing Address - Phone:773-235-8887
Mailing Address - Fax:773-235-8882
Practice Address - Street 1:5140 N CALIFORNIA AVE STE 780
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-7066
Practice Address - Country:US
Practice Address - Phone:773-235-8887
Practice Address - Fax:773-235-8882
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOFFA SURGICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-18
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361000422086S0102X, 2086S0127X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Single Specialty
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100042Medicaid
IL1630046OtherBCBSIL BSG
IL1629966OtherBCBS IL NIESS
IL1630046OtherBCBSIL BSG
IL036100042Medicaid
IL1629966OtherBCBS IL NIESS