Healthcare Provider Details

I. General information

NPI: 1316983315
Provider Name (Legal Business Name): NORTH SHORE SPORTS MEDICINE AND ORTHOPAEDIC CENTER, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 06/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1714 MILWAUKEE AVE
GLENVIEW IL
60025-1441
US

IV. Provider business mailing address

1714 MILWAUKEE AVE
GLENVIEW IL
60025-1441
US

V. Phone/Fax

Practice location:
  • Phone: 847-699-6810
  • Fax: 847-699-2854
Mailing address:
  • Phone: 847-688-6810
  • Fax: 847-699-2854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CHADWICK PRODROMOS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 847-699-6810