Provider Demographics
NPI:1710046065
Name:ILLINOIS BONE AND JOINT INSTIT
Entity Type:Organization
Organization Name:ILLINOIS BONE AND JOINT INSTIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-324-3976
Mailing Address - Street 1:5057 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4801 W PETERSON AVE
Practice Address - Street 2:STE 213
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5713
Practice Address - Country:US
Practice Address - Phone:773-777-4947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5860300022Medicare NSC