Provider Demographics
NPI:1902989379
Name:ORTHOPAEDIC AND REHABILITATION SPECIALISTS OF CENTRAL ILLINOIS
Entity Type:Organization
Organization Name:ORTHOPAEDIC AND REHABILITATION SPECIALISTS OF CENTRAL ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:TUAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-877-2088
Mailing Address - Street 1:304 W HAY ST
Mailing Address - Street 2:SUITE 218
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-6328
Mailing Address - Country:US
Mailing Address - Phone:217-877-2088
Mailing Address - Fax:217-877-3622
Practice Address - Street 1:304 W HAY ST
Practice Address - Street 2:SUITE 218
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-6328
Practice Address - Country:US
Practice Address - Phone:217-877-2088
Practice Address - Fax:217-877-3622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-22
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-109943207XX0005X
IL036-109858208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214418Medicare PIN