Provider Demographics
NPI:1023138633
Name:CHICAGO SOUTH ORTHOPEDICS, INC
Entity type:Organization
Organization Name:CHICAGO SOUTH ORTHOPEDICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPEDIC SURGEN
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:NIKKEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-423-8440
Mailing Address - Street 1:5540 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-5574
Mailing Address - Country:US
Mailing Address - Phone:708-423-8440
Mailing Address - Fax:708-658-2958
Practice Address - Street 1:5540 W 111TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5574
Practice Address - Country:US
Practice Address - Phone:708-423-8440
Practice Address - Fax:708-658-2958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31622992OtherBCBS
IL1699762336OtherNPI # INDIV.
IL$$$$$$$$$OtherSSN
IL1699762336OtherNPI # INDIV.