Healthcare Provider Details

I. General information

NPI: 1427123926
Provider Name (Legal Business Name): ORTHOPEDIC SPECIALISTS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 02/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 W NORTH AVE SUITE314
MELROSE PARK IL
60160-1634
US

IV. Provider business mailing address

360 W BUTTERFIELD ROAD SUITE160
ELMHURST IL
60126
US

V. Phone/Fax

Practice location:
  • Phone: 630-782-9600
  • Fax: 630-782-1643
Mailing address:
  • Phone: 630-782-9600
  • Fax: 630-782-1643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005007
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MS. KELLY PANCAMO
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 630-333-4447