=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235637851
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECIALTY ORTHOPAEDICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2018
-----------------------------------------------------
Last Update Date | 10/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 911 N ELM ST STE 327
-----------------------------------------------------
City | HINSDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60521-3642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-387-6589
-----------------------------------------------------
Fax | 630-387-9789
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 911 N ELM ST STE 327
-----------------------------------------------------
City | HINSDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60521-3642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-387-6589
-----------------------------------------------------
Fax | 630-387-9789
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/PRESIDENT
-----------------------------------------------------
Name | SAMUEL PARK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 630-743-1337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 036118586
-----------------------------------------------------
License Number State |
-----------------------------------------------------