Healthcare Provider Details

I. General information

NPI: 1740918887
Provider Name (Legal Business Name): ORTHOMIDWEST SURGERY CENTER BELOIT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2102 FREEMAN PARKWAY
BELOIT WI
53511
US

IV. Provider business mailing address

5875 E RIVERSIDE BLVD
ROCKFORD IL
61114-4937
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-9491
  • Fax:
Mailing address:
  • Phone: 815-381-7431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LESLIE ELMER
Title or Position: DIRECTOR, CREDENTIALING AND RISK
Credential: CPCS
Phone: 815-381-7431