Basic Information
| Provider Information | |||||||||
| NPI: | 1740349018 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLINOIS BONE AND JOINT INSTITUTE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5057 PAYSPHERE CIR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606740050 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9000 WAUKEGAN RD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MORTON GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600532127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473753000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 08/12/2011 | ||||||||
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| AuthorizedOfficialLastName: | GOLDSTEIN | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8473243976 | ||||||||
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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 | 207RR0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.