Provider Demographics
NPI:1588704613
Name:ORTHOPEDIC AND SPORTS MEDICINE PHYSICIANS, LTD
Entity type:Organization
Organization Name:ORTHOPEDIC AND SPORTS MEDICINE PHYSICIANS, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BAUMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-234-9884
Mailing Address - Street 1:4600 MEMORIAL DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226
Mailing Address - Country:US
Mailing Address - Phone:618-234-9884
Mailing Address - Fax:618-235-9020
Practice Address - Street 1:4600 MEMORIAL DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-234-9884
Practice Address - Fax:618-235-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210013Medicare ID - Type UnspecifiedGROUP NUMBER
IL5229570001Medicare NSC