Basic Information
| Provider Information | |||||||||
| NPI: | 1790189850 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BONE & JOINT SPECIALISTS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9001 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197953360 | ||||||||
| FaxNumber: | 2194720494 | ||||||||
| Practice Location | |||||||||
| Address1: | 9001 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197953360 | ||||||||
| FaxNumber: | 2194720494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2014 | ||||||||
| LastUpdateDate: | 10/20/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | CORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIVISION MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2197953360 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10001727A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 10001727A | 01 | IN | STATE LICENSE | OTHER |