Provider Demographics
NPI:1831770510
Name:MIDWEST SPORTS AND INTERVENTIONAL SPINE SC
Entity type:Organization
Organization Name:MIDWEST SPORTS AND INTERVENTIONAL SPINE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CYRIL
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILIP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-299-6199
Mailing Address - Street 1:2070 GREEN BAY RD STE 163
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2412
Mailing Address - Country:US
Mailing Address - Phone:262-299-6199
Mailing Address - Fax:262-293-6953
Practice Address - Street 1:850 GENEVA PARKWAY N
Practice Address - Street 2:STE 100
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-4562
Practice Address - Country:US
Practice Address - Phone:847-343-0711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-15
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Single Specialty