Healthcare Provider Details

I. General information

NPI: 1013313832
Provider Name (Legal Business Name): ORTHOPAEDIC CENTER OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S KOKE MILL RD
SPRINGFIELD IL
62711-9252
US

IV. Provider business mailing address

1301 S KOKE MILL RD
SPRINGFIELD IL
62711-9252
US

V. Phone/Fax

Practice location:
  • Phone: 217-547-9100
  • Fax: 217-547-9236
Mailing address:
  • Phone: 217-547-9100
  • Fax: 217-547-9236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number042007969
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number042007969
License Number StateIL

VIII. Authorized Official

Name: MELISSA SMITH
Title or Position: EXECUTIVE ADMINISTRATIVE ASSISTANT
Credential:
Phone: 217-547-9100