Provider Demographics
NPI:1861737462
Name:ADVANCED SPINAL ORTHOTICS
Entity type:Organization
Organization Name:ADVANCED SPINAL ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:K
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-770-5980
Mailing Address - Street 1:3000 N HALSTED ST
Mailing Address - Street 2:SUITE 703
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5188
Mailing Address - Country:US
Mailing Address - Phone:773-770-5980
Mailing Address - Fax:773-296-9999
Practice Address - Street 1:3000 N HALSTED ST
Practice Address - Street 2:SUITE 703
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5188
Practice Address - Country:US
Practice Address - Phone:773-770-5980
Practice Address - Fax:773-296-9999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111342332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1922099084Medicare UPIN