Provider Demographics
NPI:1104014158
Name:PRINCETON ORTHOPEDIC CLINIC, SC
Entity Type:Organization
Organization Name:PRINCETON ORTHOPEDIC CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:WILSON MD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-895-1052
Mailing Address - Street 1:9291 IL HIGHWAY 40
Mailing Address - Street 2:
Mailing Address - City:BUDA
Mailing Address - State:IL
Mailing Address - Zip Code:61314-9451
Mailing Address - Country:US
Mailing Address - Phone:309-895-1052
Mailing Address - Fax:
Practice Address - Street 1:9291 IL HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:BUDA
Practice Address - State:IL
Practice Address - Zip Code:61314-9451
Practice Address - Country:US
Practice Address - Phone:309-895-1052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty