1356513246 NPI number — NORTHSIDE EAR, NOSE AND THROAT, SC

Table of content: (NPI 1356513246)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356513246 NPI number — NORTHSIDE EAR, NOSE AND THROAT, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSIDE EAR, NOSE AND THROAT, SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356513246
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9669 N. KENTON AVE
Provider Second Line Business Mailing Address:
SUITE 605
Provider Business Mailing Address City Name:
SKOKIE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60076-1248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-674-3626
Provider Business Mailing Address Fax Number:
847-674-5250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9669 N. KENTON AVE
Provider Second Line Business Practice Location Address:
SUITE 605
Provider Business Practice Location Address City Name:
SKOKIE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60076-1248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-674-3626
Provider Business Practice Location Address Fax Number:
847-674-5250
Provider Enumeration Date:
03/31/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HORWITZ
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
847-674-3626

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM2500X , with the licence number: 036050064 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036050064 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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