Healthcare Provider Details

I. General information

NPI: 1013021922
Provider Name (Legal Business Name): NORTH SHORE UROGYNECOLOGY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 12/18/2021
Certification Date: 12/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 GREENLEAF AVE E
PARK CITY IL
60085-5701
US

IV. Provider business mailing address

351 GREENLEAF AVE E
PARK CITY IL
60085-5701
US

V. Phone/Fax

Practice location:
  • Phone: 847-234-1100
  • Fax: 847-775-0703
Mailing address:
  • Phone: 847-234-1100
  • Fax: 847-775-0703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number036101308
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036101308
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number036-101308
License Number StateIL

VIII. Authorized Official

Name: SANJAY GANDHI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 847-234-1100