=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174568828
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHERRI KLIS URSO MD SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2006
-----------------------------------------------------
Last Update Date | 04/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 799 ROOSEVELT RD STE 4-314
-----------------------------------------------------
City | GLEN ELLYN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60137-5909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-545-1477
-----------------------------------------------------
Fax | 630-545-1577
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 799 ROOSEVELT RD STE 4-314
-----------------------------------------------------
City | GLEN ELLYN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60137-5909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-886-7376
-----------------------------------------------------
Fax | 630-545-1577
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SHERRI KLIS-URSO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 630-886-7376
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 036-104305
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------