=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710261623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY ORTHOPEDICS & SPORTS MEDICINE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2011
-----------------------------------------------------
Last Update Date | 10/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 818 E BROADWAY ST 1ST FLOOR
-----------------------------------------------------
City | SPARTA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62286-1820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-443-2177
-----------------------------------------------------
Fax | 618-443-1324
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1449
-----------------------------------------------------
City | MARYLAND HEIGHTS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63043-0449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-432-2580
-----------------------------------------------------
Fax | 314-432-0223
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | MS. TAMMY ADDERLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-432-2580
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 036109093
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------