Healthcare Provider Details

I. General information

NPI: 1477049070
Provider Name (Legal Business Name): ORTHOMIDWEST, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 S RANDALL RD
ALGONQUIN IL
60102-5944
US

IV. Provider business mailing address

PO BOX 735263
CHICAGO IL
60673-5263
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-9491
  • Fax:
Mailing address:
  • Phone: 181-538-1743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: LESLIE ELMER
Title or Position: MANAGER, CREDENTIALING AND RISK MAN
Credential:
Phone: 815-381-7431