Healthcare Provider Details

I. General information

NPI: 1487606109
Provider Name (Legal Business Name): PHILIP H SHERIDAN JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2006
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: 847-675-1960
  • Fax: 847-446-1893
Mailing address:
  • Phone: 708-366-7177
  • Fax: 708-366-3301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: