Basic Information
| Provider Information | |||||||||
| NPI: | 1255635892 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDICS OF ILLINOIS - THE BONE JOINT AND SPORTS MEDICINE CENTER S | ||||||||
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| OtherOrganizationName: | ORTHO ILLINOIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 FORT JESSE RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617616290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094541616 | ||||||||
| FaxNumber: | 3094545167 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 FORT JESSE RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617616290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094541616 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2010 | ||||||||
| LastUpdateDate: | 07/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | STOUT | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3094541616 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 036108279 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.