Provider Demographics
NPI:1366615668
Name:LINCOLN TRAIL ORTHOPAEDIC CLINIC, S.C.
Entity type:Organization
Organization Name:LINCOLN TRAIL ORTHOPAEDIC CLINIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULEE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-348-1052
Mailing Address - Street 1:103 PROFESSIONAL PLZ
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-9252
Mailing Address - Country:US
Mailing Address - Phone:217-348-1030
Mailing Address - Fax:217-348-1090
Practice Address - Street 1:103 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9252
Practice Address - Country:US
Practice Address - Phone:217-348-1030
Practice Address - Fax:217-348-1090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058473207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058473Medicaid
IL791203439OtherRAILROAD MEDICARE
IL002811OtherHEALTH ALLIANCE
IL133038OtherHEALTHLINK
IL1515701OtherBLUE CROSS BLUE SHIELD
IL036058473Medicaid
IL133038OtherHEALTHLINK