MEDICARE: ILLINOIS VALLEY SPINE INSTITUTE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XS0117X	Orthopaedic Surgery of the Spine Physician	036-114114	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	IL6014	OTHER	IL	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336428192
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILLINOIS VALLEY SPINE INSTITUTE LLC

Provider Business Mailing Address
First Line	:	4231 PROGRESS BLVD
Second Line	:	4
City	:	PERU
State	:	IL
Zip	:	61354-1193
Country	:	US
Telephone Number	:	815-780-8627
Fax Number	:	815-780-8630

Provider Business Practice Location Address
First Line	:	4231 PROGRESS BLVD
Second Line	:	4
City	:	PERU
State	:	IL
Zip	:	61354-1193
Country	:	US
Telephone Number	:	815-780-8627
Fax Number	:	815-780-8630

Authorized Official
Title or Position	:	ORTHOPAEDIC SURGEON
Name	:	JASON BERGANDI
Credential	:	M.D.
Telephone Number	:	815-780-8627

Provider Enumeration Date	:	08/11/2011
Last Update Date	:	11/28/2011

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Directions to “ILLINOIS VALLEY SPINE INSTITUTE LLC ” Practice Location

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