Healthcare Provider Details

I. General information

NPI: 1356400600
Provider Name (Legal Business Name): ILLINOIS BONE AND JOINT INSTIT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 N LAKE SHORE DR SUITE 1028
CHICAGO IL
60611-4546
US

IV. Provider business mailing address

5057 PAYSPHERE CIR
CHICAGO IL
60674-0050
US

V. Phone/Fax

Practice location:
  • Phone: 312-664-6848
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: WAYNE M GOLDSTEIN
Title or Position: PRESIDENT
Credential: MD
Phone: 847-324-3976