Provider Demographics
NPI:1528153335
Name:CHICAGO MUSCULOSKELETAL INSTITUTE, S.C.
Entity type:Organization
Organization Name:CHICAGO MUSCULOSKELETAL INSTITUTE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:IVANKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-675-9900
Mailing Address - Street 1:PO BOX 1150
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-8150
Mailing Address - Country:US
Mailing Address - Phone:773-675-9900
Mailing Address - Fax:800-281-6952
Practice Address - Street 1:5025 N PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2772
Practice Address - Country:US
Practice Address - Phone:773-675-9900
Practice Address - Fax:800-281-6952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105713261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105713Medicaid
IL210362Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILH74349Medicare UPIN
ILK12440Medicare ID - Type UnspecifiedMEDICARE #