Orthopedic and Sports Enhancement Center, LLC
Organization Active NPI Specialist · Bloomington, IL
NPI 1003900820 · NPPES record last updated Sep 12, 2017
Key facts
- NPI
- 1003900820
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Specialist 174400000X
- Legal business name
- ORTHOPEDIC AND SPORTS ENHANCEMENT CENTER, LLC
- Practice address
- 2406 E Empire St
Bloomington, IL 61704-3630 - Phone
- (309) 663-9300
- Fax
- (309) 661-1670
- NPI assigned
- Oct 3, 2006
- Organization subpart
- No
Authorized official
- Name
- J. Anthony Dustman
- Title
- President
- Phone
- (309) 663-9300
Practitioners 18
-
Bradley J Cole, APRN,NP-C
-
Chris Dangles, M.D.
-
John Anthony Dustman, M.D.
-
Jill Levin, DPT
-
David McClure, M.S., P.T.
-
Tyler Jordan Neal, D.O.
-
Bryce Andrew Paschold, D.P.M.
-
Robert K Seidl, MD
-
Emily Sendelbach, DPT
-
Emily Whitted, DPT
-
Nitin Kukkar, MD
-
John Jeffrey Williamson, P.A.
-
Cody Wickenhauser, PT, DPT
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20071002000477 | IL | Part B Supplier - Clinic/Group Practice | 3375638695 |
Receives reassigned benefits from 15 practitioners Practice locations: Bloomington, IL |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Specialist |
174400000X | Yes | ||
| Orthopaedic Surgery Physician |
207X00000X |
Addresses
Primary practice location
2406 E Empire St
Bloomington, IL 61704-3630
Mailing address
2406 E Empire St
Bloomington, IL 61704-3630
Phone (309) 663-9300
Other names
- Sports Enhancement Center, LLC
Other providers in Bloomington, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 12, 2017. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.