Provider Demographics
NPI:1194730960
Name:SOUTHLAND BONE & JOINT INSTITUTE, S.C.
Entity type:Organization
Organization Name:SOUTHLAND BONE & JOINT INSTITUTE, S.C.
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 1:20060 GOVERNORS DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1029
Mailing Address - Country:US
Mailing Address - Phone:708-283-2600
Mailing Address - Fax:708-283-1250
Practice Address - Street 1:20060 GOVERNORS DR
Practice Address - Street 2:SUITE 300
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1029
Practice Address - Country:US
Practice Address - Phone:708-283-2600
Practice Address - Fax:708-283-1250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632336OtherBLUE SHIELD PROVIDER #
IN200394600BMedicaid
IN200394600BMedicaid
IL202031Medicare PIN
IL211216Medicare PIN
4571400001Medicare NSC
CK2034Medicare PIN
IN200394600BMedicaid
IN192380Medicare PIN