Healthcare Provider Details

I. General information

NPI: 1316051741
Provider Name (Legal Business Name): RIVERSIDE ORTHOPEDICS, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6641 WEST OGDEN AVENUE
BERWYN IL
60402-3756
US

IV. Provider business mailing address

6641 WEST OGDEN AVENUE
BERWYN IL
60402-3756
US

V. Phone/Fax

Practice location:
  • Phone: 708-484-9480
  • Fax: 708-484-9482
Mailing address:
  • Phone: 708-484-9480
  • Fax: 708-484-9482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number036047917
License Number StateIL

VIII. Authorized Official

Name: TARIQ BIN IFTIKHAR
Title or Position: ORTHOPEDIC SURGEON
Credential: MD
Phone: 708-484-9480