Healthcare Provider Details

I. General information

NPI: 1912170523
Provider Name (Legal Business Name): LIBERTYVILLE NEUROSURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2008
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 S MILWAUKEE AVE
LIBERTYVILLE IL
60048-3279
US

IV. Provider business mailing address

712 S MILWAUKEE AVE
LIBERTYVILLE IL
60048-3279
US

V. Phone/Fax

Practice location:
  • Phone: 847-362-1848
  • Fax: 847-362-3351
Mailing address:
  • Phone: 847-362-1848
  • Fax: 847-362-3351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JONATHAN S CITOW
Title or Position: OWNER
Credential:
Phone: 847-362-1848