Healthcare Provider Details

I. General information

NPI: 1003433392
Provider Name (Legal Business Name): ILLINOIS BONE AND JOINT INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3296 EXECUTIVE DR UNIT 201
JOLIET IL
60431-8501
US

IV. Provider business mailing address

5057 PAYPHERE CIRCLE
CHICAGO IL
60674-0001
US

V. Phone/Fax

Practice location:
  • Phone: 815-207-4223
  • Fax: 815-744-8624
Mailing address:
  • Phone: 847-324-3976
  • Fax: 847-929-1154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

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