Provider Demographics
NPI:1659522357
Name:SOUTHLAND BONE & JOINT INSTITUTE, PSC
Entity Type:Organization
Organization Name:SOUTHLAND BONE & JOINT INSTITUTE, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDI
Authorized Official - Middle Name:L
Authorized Official - Last Name:JEFFERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-283-2600
Mailing Address - Street 1:PO BOX 4097
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60507-4097
Mailing Address - Country:US
Mailing Address - Phone:708-283-2600
Mailing Address - Fax:708-283-1635
Practice Address - Street 1:7550 HOHMAN AVE STE 400
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1059
Practice Address - Country:US
Practice Address - Phone:219-513-0660
Practice Address - Fax:219-513-0670
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHLAND BONE & JOINT INSTITUTE, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-01
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50004723A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632336OtherBLUE SHIELD PROVIDER NUMBER
CK2034Medicare PIN
IN4571400002Medicare NSC
IL01632336OtherBLUE SHIELD PROVIDER NUMBER