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General NPI Number Information
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NPI Number | 1700140613
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Entity Type | Organization
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Legal Business Name | MIDAMERICA ORTHOPAEDICS, S.C.
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Dates
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Enumeration Date | 06/26/2012
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Last Update Date | 06/26/2012
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Provider Practice Location Address
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Address Line | 19065 HICKORY CREEK DR SUITE 210
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City | MOKENA
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State | IL
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Zip | 60448-8507
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Country | US
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Telephone | 708-237-7200
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Fax | 815-838-0590
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Provider Business Mailing Address
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Address Line | 19065 HICKORY CREEK DR SUITE 210
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City | MOKENA
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State | IL
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Zip | 60448-8507
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Country | US
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Telephone | 708-237-7200
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Fax | 815-838-0590
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ANTON J FAKHOURI
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Credential | M.D.
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Telephone | 708-237-7200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2082S0105X
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Taxonomy Name | Surgery of the Hand (Plastic Surgery) Physician
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License Number | 036-095853
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 036-084909
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License Number State | IL
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