MEDICARE: CHICAGO NASAL AND SINUS CENTER S C

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	207Y00000X	Otolaryngology Physician	036-087346	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	040017908	OTHER	IL	RRMC
2	0001633140	OTHER	IL	BLUE SHIELD

General Provider Information

NPI Number	:	1366497026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO NASAL AND SINUS CENTER S C

Provider Business Mailing Address
First Line	:	111 W WASHINGTON ST STE 903
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60602-2762
Country	:	US
Telephone Number	:	312-372-9355
Fax Number	:	312-372-9356

Provider Business Practice Location Address
First Line	:	111 W WASHINGTON ST
Second Line	:	SUITE 903
City	:	CHICAGO
State	:	IL
Zip	:	60602-2703
Country	:	US
Telephone Number	:	312-372-9355
Fax Number	:	312-372-9356

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	JORDAN B PRITIKIN
Credential	:	M.D.
Telephone Number	:	312-372-9355

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	09/14/2023

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