Provider Demographics
NPI:1952589632
Name:WOODFIELD ORTHOPAEDICS SPORTS MEDICINE
Entity Type:Organization
Organization Name:WOODFIELD ORTHOPAEDICS SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-301-7773
Mailing Address - Street 1:1102 S ROSELLE RD
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-4081
Mailing Address - Country:US
Mailing Address - Phone:847-301-7773
Mailing Address - Fax:847-301-6506
Practice Address - Street 1:750 FLETCHER DR
Practice Address - Street 2:SUITE 305
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4703
Practice Address - Country:US
Practice Address - Phone:847-301-7773
Practice Address - Fax:847-301-6506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01635715OtherBCBS PROVIDER NUMBER
ILD93938Medicare UPIN