Provider Demographics
NPI:1316069651
Name:ADULT & PEDIATRIC ORTHOPEDICS, S.C.
Entity type:Organization
Organization Name:ADULT & PEDIATRIC ORTHOPEDICS, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGENNARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-634-0400
Mailing Address - Street 1:50 S MILWAUKEE AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-5426
Mailing Address - Country:US
Mailing Address - Phone:224-372-7880
Mailing Address - Fax:224-372-7870
Practice Address - Street 1:50 S MILWAUKEE AVE
Practice Address - Street 2:STE 201
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-9471
Practice Address - Country:US
Practice Address - Phone:224-372-7880
Practice Address - Fax:224-372-7870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042005991207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL751320Medicare PIN
IL5926900003Medicare NSC