1992980627 NPI number — PHILIP H SHERIDAN JR SC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992980627 NPI number — PHILIP H SHERIDAN JR SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILIP H SHERIDAN JR 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:
1992980627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 616
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60130-0616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-366-7177
Provider Business Mailing Address Fax Number:
708-366-3301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2650 RIDGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60201-1718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-657-1960
Provider Business Practice Location Address Fax Number:
847-446-1893
Provider Enumeration Date:
12/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHERIDAN
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-774-7836

Provider Taxonomy Codes

  • Taxonomy code: 207RC0200X , with the licence number:  036079226 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 036079226 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 216062 . This is a "MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 01637916 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036079226 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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