Healthcare Provider Details

I. General information

NPI: 1104863638
Provider Name (Legal Business Name): MIDLAND ORTHOPEDIC ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 S WABASH AVE SUITE 100
CHICAGO IL
60616-2955
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 312-842-4600
  • Fax: 312-842-8694
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number042007805
License Number StateIL

VIII. Authorized Official

Name: DANIEL GOGGIN
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 312-842-4600