=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053536375
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BJG MD SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2007
-----------------------------------------------------
Last Update Date | 12/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4709 GOLF RD SUITE 107
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60076-1231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-675-5775
-----------------------------------------------------
Fax | 847-674-4387
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4709 GOLF RD SUITE 107
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60076-1231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-675-5775
-----------------------------------------------------
Fax | 847-674-4387
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRUCE J GOLDSTICK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 847-675-5775
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------