=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073623112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES J OLAUGHLIN JR MD SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 BIESTERFIELD RD SUITE 4009, BROCK BLDG
-----------------------------------------------------
City | ELK GROVE VILLAGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60007-3311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-364-7717
-----------------------------------------------------
Fax | 847-364-7748
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 BIESTERFIELD RD SUITE 4009, BROCK BLDG
-----------------------------------------------------
City | ELK GROVE VILLAGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60007-3311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-364-7717
-----------------------------------------------------
Fax | 847-364-7748
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. CHARLES J O'LAUGHLIN JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 847-364-7717
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 036-053819
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------