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General NPI Number Information
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NPI Number | 1295351062
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Entity Type | Organization
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Legal Business Name | SARA M GOTHERIDGE MD LLC
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Dates
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Enumeration Date | 06/17/2020
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Last Update Date | 06/17/2020
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Provider Practice Location Address
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Address Line | 630 DAVIS ST STE 301
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City | EVANSTON
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State | IL
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Zip | 60201-4480
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Country | US
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Telephone | 312-640-7731
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Fax | 877-421-1846
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Provider Business Mailing Address
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Address Line | 2412 LAWNDALE AVE
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City | EVANSTON
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State | IL
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Zip | 60201-1854
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Country | US
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Telephone | 312-608-4996
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Fax | 877-421-1846
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SARA MARGARET GOTHERIDGE
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Credential | MD
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Telephone | 312-640-7731
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State |
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