Healthcare Provider Details

I. General information

NPI: 1992980627
Provider Name (Legal Business Name): PHILIP H SHERIDAN JR SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 08/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE
EVANSTON IL
60201-1718
US

IV. Provider business mailing address

PO BOX 616
FOREST PARK IL
60130-0616
US

V. Phone/Fax

Practice location:
  • Phone: 847-657-1960
  • Fax: 847-446-1893
Mailing address:
  • Phone: 708-366-7177
  • Fax: 708-366-3301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036079226
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036079226
License Number StateIL

VIII. Authorized Official

Name: PHILIP H SHERIDAN JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 847-774-7836