Healthcare Provider Details

I. General information

NPI: 1578748034
Provider Name (Legal Business Name): PHYSICIANS PLUS BERWYN LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 W RANDOLPH ST 1205
CHICAGO IL
60606-1867
US

IV. Provider business mailing address

205 W RANDOLPH ST 1205
CHICAGO IL
60606-1867
US

V. Phone/Fax

Practice location:
  • Phone: 312-265-6908
  • Fax: 312-264-0347
Mailing address:
  • Phone: 312-265-6908
  • Fax: 312-264-0347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number038009369
License Number StateIL

VIII. Authorized Official

Name: DR. SCOTT SPENCER
Title or Position: CHIROPRACTIC PHYSICIAN
Credential: D.C.
Phone: 312-265-6908