MEDICARE: LINCOLN TRAIL ORTHOPAEDIC CLINIC, S.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	036058473	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	791203439	OTHER	IL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	002811	OTHER	IL	HEALTH ALLIANCE
4	133038	OTHER	IL	HEALTHLINK
5	1515701	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1366615668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LINCOLN TRAIL ORTHOPAEDIC CLINIC, S.C.

Provider Business Mailing Address
First Line	:	103 PROFESSIONAL PLZ
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-9252
Country	:	US
Telephone Number	:	217-348-1030
Fax Number	:	217-348-1090

Provider Business Practice Location Address
First Line	:	103 PROFESSIONAL PLZ
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-9252
Country	:	US
Telephone Number	:	217-348-1030
Fax Number	:	217-348-1090

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. JULEE LEE
Credential	:
Telephone Number	:	217-348-1052

Provider Enumeration Date	:	04/08/2008
Last Update Date	:	04/08/2008

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Directions to “LINCOLN TRAIL ORTHOPAEDIC CLINIC, S.C. ” Practice Location

Language	Start Address	Practice Location

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