Provider First Line Business Practice Location Address:
2703 ASHLAND AVE
Provider Second Line Business Practice Location Address:
NORTHWESTERN UNIVERSITY SPORTS MEDICINE
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60208-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-467-6791
Provider Business Practice Location Address Fax Number:
847-491-8865
Provider Enumeration Date:
01/26/2010