Provider Demographics
NPI:1174968820
Name:MIDWEST ILLINOIS ORTHOTICS LLC
Entity type:Organization
Organization Name:MIDWEST ILLINOIS ORTHOTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-821-2600
Mailing Address - Street 1:12166 OLD BIG BEND RD
Mailing Address - Street 2:STE 303
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-6844
Mailing Address - Country:US
Mailing Address - Phone:314-821-2600
Mailing Address - Fax:888-770-2935
Practice Address - Street 1:11425 DORSETT RD
Practice Address - Street 2:STE B
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-3445
Practice Address - Country:US
Practice Address - Phone:314-739-4408
Practice Address - Fax:888-770-2935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
6777510001Medicare NSC