Healthcare Provider Details

I. General information

NPI: 1366844714
Provider Name (Legal Business Name): ILLINOIS BONE AND JOINT INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 03/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6308 8TH AVE SUITE 2000
KENOSHA WI
53143-5031
US

IV. Provider business mailing address

900 RAND RD SUITE 300
DES PLAINES IL
60016-2359
US

V. Phone/Fax

Practice location:
  • Phone: 262-656-3590
  • Fax: 262-656-3591
Mailing address:
  • Phone: 847-324-3976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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: 847-375-3000