Provider Demographics
NPI:1740277102
Name:ORTHOPEDIC ASSOCIATES OF NORTHERN ILLINOIS, LLC
Entity type:Organization
Organization Name:ORTHOPEDIC ASSOCIATES OF NORTHERN ILLINOIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PALMER-BEARD
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:815-484-9999
Mailing Address - Street 1:1235 N MULFORD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3879
Mailing Address - Country:US
Mailing Address - Phone:815-484-9999
Mailing Address - Fax:815-484-4255
Practice Address - Street 1:1235 N MULFORD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3879
Practice Address - Country:US
Practice Address - Phone:815-484-9999
Practice Address - Fax:815-484-4255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL569700Medicare ID - Type Unspecified
IL6183140001Medicare NSC