Provider Demographics
NPI:1144205600
Name:MIDWEST MINIMALLY INVASIVE SPINE SPECIALISTS SC
Entity type:Organization
Organization Name:MIDWEST MINIMALLY INVASIVE SPINE SPECIALISTS SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:SWEENEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-390-2290
Mailing Address - Street 1:PO BOX 4037
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60507-4037
Mailing Address - Country:US
Mailing Address - Phone:708-390-2290
Mailing Address - Fax:708-390-2299
Practice Address - Street 1:19110 DARVIN DR
Practice Address - Street 2:SUITE C
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8595
Practice Address - Country:US
Practice Address - Phone:708-390-2290
Practice Address - Fax:708-390-2299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042617626207T00000X
IN50004759A207T00000X
IL50004759A207XS0117X
IN042617626207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDO9194OtherRR MEDICARE
01632167OtherBC/BS
INCK7919OtherRR MEDICARE
IL201029Medicare PIN
INCK7919OtherRR MEDICARE
ILIL1703Medicare PIN
IN188880Medicare PIN