Healthcare Provider Details

I. General information

NPI: 1235499369
Provider Name (Legal Business Name): NORTHWESTERN OBSTETRICS AND GYNECOLOGY CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 LAKE COOK ROAD SUITE 604
NORTHBROOK IL
60062
US

IV. Provider business mailing address

676 N SAINT CLAIR ST #1880
CHICAGO IL
60611-2927
US

V. Phone/Fax

Practice location:
  • Phone: 312-642-9844
  • Fax: 312-642-7637
Mailing address:
  • Phone: 312-642-9844
  • Fax: 312-642-7637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: TERRY WAITE
Title or Position: OFFICE MANAGER
Credential:
Phone: 312-642-9844