Healthcare Provider Details

I. General information

NPI: 1134207111
Provider Name (Legal Business Name): NORTHSIDE NEONATAL AND INFANT CARE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 W WELLINGTON
CHICAGO IL
60657
US

IV. Provider business mailing address

9410 COMPUBILL DRIVE
CHICAGO IL
60462
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-7047
  • Fax: 773-296-7459
Mailing address:
  • Phone: 708-460-7444
  • Fax: 708-460-8662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: VIVEK GHAI
Title or Position: PRESIDENT
Credential: MD
Phone: 630-655-4707