Provider Demographics
NPI:1336586114
Name:DECATUR ORTHOPEDIC CENTER, LLC
Entity Type:Organization
Organization Name:DECATUR ORTHOPEDIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:D
Authorized Official - Last Name:SAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-864-2665
Mailing Address - Street 1:104 ASHLAND AVE.
Mailing Address - Street 2:
Mailing Address - City:MT. ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549
Mailing Address - Country:US
Mailing Address - Phone:217-864-2665
Mailing Address - Fax:
Practice Address - Street 1:104 ASHLAND AVE.
Practice Address - Street 2:
Practice Address - City:MT. ZION
Practice Address - State:IL
Practice Address - Zip Code:62549
Practice Address - Country:US
Practice Address - Phone:217-864-2665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-03
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-052745207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1730340498OtherINDIVIDUAL NPI
IL1154511517OtherINDIVIDUAL NPI