Provider Demographics
NPI:1861772261
Name:MIDWEST BONE & JOINT SURGERY
Entity type:Organization
Organization Name:MIDWEST BONE & JOINT SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPEDIC SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:FELIX
Authorized Official - Middle Name:
Authorized Official - Last Name:UNGACTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-541-1406
Mailing Address - Street 1:30 APEX DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1285
Mailing Address - Country:US
Mailing Address - Phone:618-654-5400
Mailing Address - Fax:618-654-8787
Practice Address - Street 1:11155 DUNN RD
Practice Address - Street 2:SUITE 204
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6150
Practice Address - Country:US
Practice Address - Phone:618-654-5400
Practice Address - Fax:618-654-8787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106268207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL215632OtherMEDICARE GROUP PROVIDER #