Provider Demographics
NPI:1285964361
Name:EAST CENTRAL ILLINOIS ORTHOPEDICS & SPORTS MEDICINE LTD
Entity type:Organization
Organization Name:EAST CENTRAL ILLINOIS ORTHOPEDICS & SPORTS MEDICINE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:T
Authorized Official - Last Name:HOGG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:217-442-2054
Mailing Address - Street 1:205 W BOUTZ RD
Mailing Address - Street 2:BLDG 1
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3259
Mailing Address - Country:US
Mailing Address - Phone:575-532-7000
Mailing Address - Fax:575-532-7006
Practice Address - Street 1:737 N LOGAN AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4363
Practice Address - Country:US
Practice Address - Phone:217-442-2054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6362530001Medicare NSC