MEDICARE: NORTH SHORE PHYSICIANS GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1093768228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH SHORE PHYSICIANS GROUP, LLC

Provider Business Mailing Address
First Line	:	525 WINNETKA AVE
Second Line	:
City	:	WINNETKA
State	:	IL
Zip	:	60093-4050
Country	:	US
Telephone Number	:	847-501-4060
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 WINNETKA AVE
Second Line	:
City	:	WINNETKA
State	:	IL
Zip	:	60093-4050
Country	:	US
Telephone Number	:	847-501-4060
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED REPRESENTATIVE
Name	:	JOHN E CROGHAN
Credential	:	MD
Telephone Number	:	847-251-1500

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	07/11/2007

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