Healthcare Provider Details

I. General information

NPI: 1346866373
Provider Name (Legal Business Name): ORTHOMIDWEST, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4119 W SHAMROCK LN
MCHENRY IL
60050-8268
US

IV. Provider business mailing address

5875 E RIVERSIDE BLVD
ROCKFORD IL
61114-4937
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-9491
  • Fax:
Mailing address:
  • Phone: 815-381-7431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: LESLIE ELMER
Title or Position: MANAGER, CREDENTIALING AND RISK MAN
Credential: CPCS
Phone: 815-381-7431