Provider Demographics
NPI:1336428192
Name:ILLINOIS VALLEY SPINE INSTITUTE LLC
Entity type:Organization
Organization Name:ILLINOIS VALLEY SPINE INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPAEDIC SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGANDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-780-8627
Mailing Address - Street 1:4231 PROGRESS BLVD
Mailing Address - Street 2:4
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-1193
Mailing Address - Country:US
Mailing Address - Phone:815-780-8627
Mailing Address - Fax:815-780-8630
Practice Address - Street 1:4231 PROGRESS BLVD
Practice Address - Street 2:4
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1193
Practice Address - Country:US
Practice Address - Phone:815-780-8627
Practice Address - Fax:815-780-8630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-11
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-114114207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-114114Medicaid
ILIL6014OtherMEDICARE
IL036-114114Medicaid