Provider Demographics
NPI:1780885343
Name:MIDWEST SPORTS MEDICINE INSTITUTE
Entity type:Organization
Organization Name:MIDWEST SPORTS MEDICINE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BURT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-267-8825
Mailing Address - Street 1:24600 W 127TH ST BLDG B SUITE 240
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-9502
Mailing Address - Country:US
Mailing Address - Phone:815-267-8825
Mailing Address - Fax:815-267-8840
Practice Address - Street 1:24600 W 127TH ST BLDG B SUITE 240
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-9502
Practice Address - Country:US
Practice Address - Phone:815-267-8825
Practice Address - Fax:815-267-8840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-111005207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9932533OtherBLUE CROSS BLUE SHIELD
IL6184170001Medicare NSC
ILH53260Medicare UPIN
IL215298Medicare PIN
ILK39402Medicare PIN