=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033723069
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLINOIS BONE AND JOINT INSTITUTE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2020
-----------------------------------------------------
Last Update Date | 09/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1870 SILVER CROSS BLVD STE 200
-----------------------------------------------------
City | NEW LENOX
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60451-8646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-462-9294
-----------------------------------------------------
Fax | 815-462-1032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 RAND RD STE 300
-----------------------------------------------------
City | DES PLAINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60016-2359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-324-3976
-----------------------------------------------------
Fax | 847-929-1154
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | WAYNE GOLDSTEIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-324-3976
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------