Healthcare Provider Details

I. General information

NPI: 1972611044
Provider Name (Legal Business Name): ORTHOPEDIC & SPORTS MEDICINE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 03/23/2011
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

PO BOX 1645
BLOOMINGTON IL
61702-1645
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-1616
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number042-616684
License Number StateIL

VIII. Authorized Official

Name: STEPHEN STOUT
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 309-454-1616