MEDICARE: OMNI ORTHOPEDIC SERVICES INC

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	335E00000X	Prosthetic/Orthotic Supplier		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2570567	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1780870576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNI ORTHOPEDIC SERVICES INC

Provider Business Mailing Address
First Line	:	108 W WASHINGTON AVE
Second Line	:
City	:	EFFINGHAM
State	:	IL
Zip	:	62401-2354
Country	:	US
Telephone Number	:	217-347-2800
Fax Number	:	217-347-2812

Provider Business Practice Location Address
First Line	:	108 W WASHINGTON AVE
Second Line	:
City	:	EFFINGHAM
State	:	IL
Zip	:	62401-2354
Country	:	US
Telephone Number	:	217-347-2800
Fax Number	:	217-347-2812

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DAVID PROCTER
Credential	:	C.P.O.
Telephone Number	:	217-347-2800

Provider Enumeration Date	:	09/14/2007
Last Update Date	:	04/20/2008

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Directions to “OMNI ORTHOPEDIC SERVICES INC ” Practice Location

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