Healthcare Provider Details

I. General information

NPI: 1710296934
Provider Name (Legal Business Name): NORTHSIDE NEUROSURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 06/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N HALSTED ST SUITE 605
CHICAGO IL
60657-5188
US

IV. Provider business mailing address

712 S MILWAUKEE AVE
LIBERTYVILLE IL
60048-3279
US

V. Phone/Fax

Practice location:
  • Phone: 773-348-4333
  • Fax: 773-348-2434
Mailing address:
  • Phone: 847-362-1848
  • Fax: 847-362-2588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: BETSY M MATTHEWS
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 847-990-1463