Provider Demographics
NPI:1104330034
Name:HINSDALE ORTHOPAEDIC ASSOCIATES, S.C.
Entity type:Organization
Organization Name:HINSDALE ORTHOPAEDIC ASSOCIATES, S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:RADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-794-8671
Mailing Address - Street 1:550 W OGDEN AVE
Mailing Address - Street 2:ATTN MARY ALICE RADFORD
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3186
Mailing Address - Country:US
Mailing Address - Phone:630-794-8671
Mailing Address - Fax:630-794-8629
Practice Address - Street 1:8141 S CALUMET AVE
Practice Address - Street 2:UNIT 1
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321
Practice Address - Country:US
Practice Address - Phone:630-323-6116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HINSDALE ORTHOPAEDIC ASSOCIATES, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50005393A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN500005393AOtherMEDICAL CORPORATION LICENSE