Basic Information
| Provider Information | |||||||||
| NPI: | 1528040490 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASINI | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 PAYSPHERE CIR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606740018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304699200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1801 S HIGHLAND AVE | ||||||||
| Address2: | STE 220 | ||||||||
| City: | LOMBARD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601484932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308738700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 01/20/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0114X | 036063475 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XS0117X | 036063475 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 036063475 | 05 | IL | MEDICAID |