Provider Demographics
NPI:1700140613
Name:MIDAMERICA ORTHOPAEDICS, S.C.
Entity Type:Organization
Organization Name:MIDAMERICA ORTHOPAEDICS, S.C.
Other - Org Name:MIDAMERICA HAND TO SHOULDER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTON
Authorized Official - Middle Name:J
Authorized Official - Last Name:FAKHOURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-237-7200
Mailing Address - Street 1:19065 HICKORY CREEK DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8507
Mailing Address - Country:US
Mailing Address - Phone:708-237-7200
Mailing Address - Fax:815-838-0590
Practice Address - Street 1:19065 HICKORY CREEK DR
Practice Address - Street 2:SUITE 210
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8507
Practice Address - Country:US
Practice Address - Phone:708-237-7200
Practice Address - Fax:815-838-0590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-084909207X00000X
IL036-0958532082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty