1346633971 NPI number — WINNETKA AVENUE PHYSICIANS, SC

Table of content: MR. CHAD EUGENE MCINTIRE P.T. (NPI 1053322644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346633971 NPI number — WINNETKA AVENUE PHYSICIANS, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WINNETKA AVENUE PHYSICIANS, 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:
1346633971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2215 SANDERS RD
Provider Second Line Business Mailing Address:
STE 105
Provider Business Mailing Address City Name:
NORTHBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60062-6126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
224-330-6300
Provider Business Mailing Address Fax Number:
224-330-6325

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 WINNETKA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINNETKA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60093-4050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-501-5060
Provider Business Practice Location Address Fax Number:
847-501-4063
Provider Enumeration Date:
03/06/2015

Additional Information

Authorized Official

Authorized Official Last Name:
STERN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
847-501-4060

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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