Healthcare Provider Details

I. General information

NPI: 1144220724
Provider Name (Legal Business Name): MIDWEST SPORTS MEDICINE & ORTHOPAEDIC SURGICAL SPECIALISTS, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 BIESTERFIELD RD SUITE 300
ELK GROVE VILLAGE IL
60007-3392
US

IV. Provider business mailing address

901 BIESTERFIELD RD SUITE 300
ELK GROVE VILLAGE IL
60007-3392
US

V. Phone/Fax

Practice location:
  • Phone: 847-437-9889
  • Fax: 847-437-4149
Mailing address:
  • Phone: 847-437-9889
  • Fax: 847-437-4149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number042-006737
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateIL

VIII. Authorized Official

Name: MS. EUGENE LOPEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 847-437-9889