Healthcare Provider Details

I. General information

NPI: 1073869574
Provider Name (Legal Business Name): NORTHSTAR INTEGRATED HEALTH & PHYSICAL MEDICINE CENTER, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4513 LINCOLN AVE #212
LISLE IL
60532-1289
US

IV. Provider business mailing address

4513 LINCOLN AVE #212
LISLE IL
60532-1289
US

V. Phone/Fax

Practice location:
  • Phone: 630-795-1889
  • Fax:
Mailing address:
  • Phone: 630-795-1889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number038010007
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number041384754
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number036110569
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number036111510
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036111510
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number036110569
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070019141
License Number StateIL
# 8
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209009686
License Number StateIL
# 9
Primary TaxonomyN
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number209009686
License Number StateIL
# 10
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateIL
# 11
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209009686
License Number StateIL

VIII. Authorized Official

Name: DR. PAUL RIESELMAN
Title or Position: OWNER
Credential:
Phone: 630-795-1889