Healthcare Provider Details

I. General information

NPI: 1558714352
Provider Name (Legal Business Name): NEUROLOGY CENTERS OF ILLINOIS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8269 W GOLF RD
NILES IL
60714-1156
US

IV. Provider business mailing address

8269 W GOLF RD
NILES IL
60714-1156
US

V. Phone/Fax

Practice location:
  • Phone: 847-299-7000
  • Fax:
Mailing address:
  • Phone: 847-299-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036133912
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number036133912
License Number StateIL

VIII. Authorized Official

Name: PETER SLAVIN
Title or Position: PRESIDENT
Credential: DC
Phone: 847-299-7000