Provider Demographics
NPI:1427123926
Name:ORTHOPEDIC SPECIALISTS SC
Entity type:Organization
Organization Name:ORTHOPEDIC SPECIALISTS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PANCAMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-333-4447
Mailing Address - Street 1:360 W BUTTERFIELD ROAD
Mailing Address - Street 2:SUITE160
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126
Mailing Address - Country:US
Mailing Address - Phone:630-782-9600
Mailing Address - Fax:630-782-1643
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:SUITE314
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1634
Practice Address - Country:US
Practice Address - Phone:630-782-9600
Practice Address - Fax:630-782-1643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X, 208100000X, 363A00000X
IL016005007213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02222323OtherBCBS
IL210678Medicare PIN
IL02222323OtherBCBS
0139440001Medicare NSC