Healthcare Provider Details

I. General information

NPI: 1538277736
Provider Name (Legal Business Name): GREENLEAF ORTHOPAEDIC ASSOCIATES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N GREENLEAF ST
GURNEE IL
60031-3326
US

IV. Provider business mailing address

105 N GREENLEAF ST
GURNEE IL
60031-3326
US

V. Phone/Fax

Practice location:
  • Phone: 847-623-3090
  • Fax: 847-623-9620
Mailing address:
  • Phone: 847-623-3090
  • Fax: 847-623-9620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. LINDA H. MILLER
Title or Position: OFFICE MANAGER
Credential:
Phone: 847-623-3090