Healthcare Provider Details

I. General information

NPI: 1194040808
Provider Name (Legal Business Name): SUBURBAN ORTHOPAEDICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2010
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 BIESTERFIELD RD STE 565
ELK GROVE VILLAGE IL
60007-3361
US

IV. Provider business mailing address

1110 W SCHICK RD
BARTLETT IL
60103-3007
US

V. Phone/Fax

Practice location:
  • Phone: 847-439-9488
  • Fax: 847-439-9498
Mailing address:
  • Phone: 630-372-1100
  • Fax: 630-372-6230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038007742
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036064932
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number036097451
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number070012618
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085001660
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085002852
License Number StateIL

VIII. Authorized Official

Name: EDWARD ORTIZ
Title or Position: PRACTICE & COMPLIANCE ADMINISTRATOR
Credential:
Phone: 630-372-1100