MEDICARE: NORTH SHORE WELLNESS CENTER LTD

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	103T00000X	Psychologist		IL

General Provider Information

NPI Number	:	1609851740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH SHORE WELLNESS CENTER LTD

Provider Business Mailing Address
First Line	:	606 ACADEMY DR
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-2421
Country	:	US
Telephone Number	:	847-559-0680
Fax Number	:	847-559-0859

Provider Business Practice Location Address
First Line	:	7300 W COLLEGE DR
Second Line	:	SUITE 101
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1152
Country	:	US
Telephone Number	:	708-448-8470
Fax Number	:	708-448-9651

Authorized Official
Title or Position	:	LIC CLINICAL PSYCHOLOGIST
Name	:	DR. RICHARD A MARKIN
Credential	:	PHD
Telephone Number	:	708-448-8470

Provider Enumeration Date	:	12/13/2005
Last Update Date	:	08/22/2020

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