NPIMap

Organization Active NPI

Orthopedic and Sports Enhancement Center, LLC

  • Specialist
  • Bloomington, IL
National Provider Identifier
1003900820
Registry record updated Sep 12, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 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
Last updated
Sep 12, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 12, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
J. Anthony Dustman
Title
President
Phone
(309) 663-9300

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 174400000X Primary
Orthopaedic Surgery PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 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 1

  • Sports Enhancement Center, LLC Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20071002000477 IL Part B Supplier - Clinic/Group Practice 3375638695 Receives reassigned benefits from 15 practitioners
Practice locations: Bloomington, IL

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 18

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 18

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159833600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1505174400000",
    "number": "1003900820",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2406 E EMPIRE ST",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617043630",
            "telephone_number": "309-663-9300",
            "fax_number": "309-661-1670"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2406 E EMPIRE ST",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617043630",
            "telephone_number": "309-663-9300",
            "fax_number": "309-661-1670"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ORTHOPEDIC AND SPORTS ENHANCEMENT CENTER, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-03",
        "last_updated": "2017-09-12",
        "status": "A",
        "authorized_official_last_name": "DUSTMAN",
        "authorized_official_first_name": "J. ANTHONY",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "309-663-9300"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Specialist",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207X00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Orthopaedic Surgery",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Sports Enhancement Center, LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Bloomington, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 12, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.