Provider Demographics
NPI:1396765848
Name:ADVANCED ORTHOPEDIC CLINIC LLC
Entity type:Organization
Organization Name:ADVANCED ORTHOPEDIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-288-8885
Mailing Address - Street 1:3 COUNTRY CLUB EXECUTIVE PARK
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1583
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 COUNTRY CLUB EXECUTIVE PARK
Practice Address - Street 2:SUITE 100
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1583
Practice Address - Country:US
Practice Address - Phone:618-288-8885
Practice Address - Fax:618-288-8886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060200207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6039260001Medicare NSC
ILD14993Medicare UPIN