Healthcare Provider Details

I. General information

NPI: 1790189850
Provider Name (Legal Business Name): BONE & JOINT SPECIALISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9001 BROADWAY
MERRILLVILLE IN
46410-7041
US

IV. Provider business mailing address

9001 BROADWAY
MERRILLVILLE IN
46410-7041
US

V. Phone/Fax

Practice location:
  • Phone: 219-795-3360
  • Fax: 219-472-0494
Mailing address:
  • Phone: 219-795-3360
  • Fax: 219-472-0494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001727A
License Number StateIN

VIII. Authorized Official

Name: CORI JOHNSON
Title or Position: DIVISION MANAGER
Credential:
Phone: 219-795-3360