Healthcare Provider Details

I. General information

NPI: 1104330034
Provider Name (Legal Business Name): HINSDALE ORTHOPAEDIC ASSOCIATES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2017
Last Update Date: 11/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8141 S CALUMET AVE UNIT 1
MUNSTER IN
46321
US

IV. Provider business mailing address

550 W OGDEN AVE ATTN MARY ALICE RADFORD
HINSDALE IL
60521-3186
US

V. Phone/Fax

Practice location:
  • Phone: 630-323-6116
  • Fax:
Mailing address:
  • Phone: 630-794-8671
  • Fax: 630-794-8629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number50005393A
License Number StateIN

VIII. Authorized Official

Name: MARY ALICE RADFORD
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 630-794-8671