Healthcare Provider Details

I. General information

NPI: 1104014158
Provider Name (Legal Business Name): PRINCETON ORTHOPEDIC CLINIC, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 10/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9291 IL HIGHWAY 40
BUDA IL
61314-9451
US

IV. Provider business mailing address

9291 IL HIGHWAY 40
BUDA IL
61314-9451
US

V. Phone/Fax

Practice location:
  • Phone: 309-895-1052
  • Fax:
Mailing address:
  • Phone: 309-895-1052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES HOWARD WILSON MD
Title or Position: CEO
Credential: MD
Phone: 309-895-1052