Healthcare Provider Details

I. General information

NPI: 1780198887
Provider Name (Legal Business Name): MIOMED ORTHOPAEDICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 N CLARK ST STE 207
CHICAGO IL
60614-1850
US

IV. Provider business mailing address

2506 N CLARK ST STE 290
CHICAGO IL
60614-1848
US

V. Phone/Fax

Practice location:
  • Phone: 773-477-8991
  • Fax: 773-477-4001
Mailing address:
  • Phone: 773-477-8991
  • Fax: 773-477-4001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MARK ALEXANDER SORENSEN
Title or Position: PRESIDENT
Credential:
Phone: 773-477-8991