Basic Information
| Provider Information | |||||||||
| NPI: | 1366844714 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLINOIS BONE AND JOINT INSTITUTE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 RAND RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600162359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473243976 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6308 8TH AVE | ||||||||
| Address2: | SUITE 2000 | ||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531435031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626563590 | ||||||||
| FaxNumber: | 2626563591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2014 | ||||||||
| LastUpdateDate: | 03/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | GOLDSTEIN | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8473753000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.