Healthcare Provider Details

I. General information

NPI: 1487923330
Provider Name (Legal Business Name): ALBERT GEORGE MITSOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5675 PORT CLINTON RD
LONG GROVE IL
60047-5059
US

IV. Provider business mailing address

5675 PORT CLINTON RD
LONG GROVE IL
60047-5059
US

V. Phone/Fax

Practice location:
  • Phone: 847-634-2206
  • Fax: 847-821-1108
Mailing address:
  • Phone: 847-634-2206
  • Fax: 847-821-1108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number036.057690
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: