=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982400107
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLINOIS BONE AND JOINT INSTITUTE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2025
-----------------------------------------------------
Last Update Date | 07/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 S GREENLEAF ST STE 202-F
-----------------------------------------------------
City | GURNEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60031-3399
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-336-3335
-----------------------------------------------------
Fax | 847-336-3249
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 RAND RD
-----------------------------------------------------
City | DES PLAINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60016-2359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-324-3976
-----------------------------------------------------
Fax | 847-929-1154
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | RAQUEL LEON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-324-3976
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------