Healthcare Provider Details

I. General information

NPI: 1437453073
Provider Name (Legal Business Name): ORTHOPEDIC & SHOULDER CENTER, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2010
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT JESSE RD STE 250
NORMAL IL
61761-6290
US

IV. Provider business mailing address

2200 FORT JESSE ROAD SUITE 250
NORMAL IL
61761
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-1616
  • Fax: 309-454-5167
Mailing address:
  • Phone: 309-888-9800
  • Fax: 309-828-9700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036092458
License Number StateIL

VIII. Authorized Official

Name: BRANDI MEISNER
Title or Position: ADMINISTRATOR
Credential:
Phone: 309-888-9800