=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750849428
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OVATION HAND INSTITUTE-ILLINOIS, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2019
-----------------------------------------------------
Last Update Date | 01/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 737 N MICHIGAN AVE STE 2200
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-6750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-432-1600
-----------------------------------------------------
Fax | 920-915-9210
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10532 N PORT WASHINGTON RD STE 1A
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53092-5563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-432-1600
-----------------------------------------------------
Fax | 262-302-4075
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN ASSISTANT
-----------------------------------------------------
Name | TARRAH O'DONNELL
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 844-432-1600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0106X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Hand Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2082S0105X
-----------------------------------------------------
Taxonomy Name | Surgery of the Hand (Plastic Surgery) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------