Healthcare Provider Details

I. General information

NPI: 1255635892
Provider Name (Legal Business Name): ORTHOPEDICS OF ILLINOIS - THE BONE JOINT AND SPORTS MEDICINE CENTER S
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2010
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT JESSE RD STE 250
NORMAL IL
61761-6290
US

IV. Provider business mailing address

2200 FORT JESSE RD STE 250
NORMAL IL
61761-6290
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-1616
  • Fax:
Mailing address:
  • Phone: 309-454-1616
  • Fax: 309-454-5167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036108279
License Number StateIL

VIII. Authorized Official

Name: STEPHEN STOUT
Title or Position: ADMINISTRATOR
Credential:
Phone: 309-454-1616