Healthcare Provider Details

I. General information

NPI: 1750898367
Provider Name (Legal Business Name): NSO A NSO MD MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE. IM/ICU HOSPITALISTS
BURR EVANSTON IL
60201-1718
US

IV. Provider business mailing address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-1010
  • Fax: 847-733-5108
Mailing address:
  • Phone: 847-570-1010
  • Fax: 847-733-5108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036167294
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number125079225
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036167294
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036167294
License Number StateIL
# 10
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036167294
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: