Healthcare Provider Details

I. General information

NPI: 1154379485
Provider Name (Legal Business Name): UNIVERSITY NEUROSURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST SUITE 970
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

1725 W HARRISON ST SUITE 970
CHICAGO IL
60612-3841
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6644
  • Fax:
Mailing address:
  • Phone: 312-942-6644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA ELLIS
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 312-942-6644