Provider Demographics
NPI:1568656874
Name:ADVANCED ORTHOPAEDIC CENTER SC
Entity type:Organization
Organization Name:ADVANCED ORTHOPAEDIC CENTER SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-344-1400
Mailing Address - Street 1:616 S IL ROUTE 31
Mailing Address - Street 2:D
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8269
Mailing Address - Country:US
Mailing Address - Phone:815-344-1400
Mailing Address - Fax:815-344-2173
Practice Address - Street 1:616 S IL ROUTE 31
Practice Address - Street 2:D
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8269
Practice Address - Country:US
Practice Address - Phone:815-344-1400
Practice Address - Fax:815-344-2173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053871174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D14647Medicare UPIN