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General NPI Number Information
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NPI Number | 1295950517
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Entity Type | Organization
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Legal Business Name | NEUROCENTER S C
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Dates
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Enumeration Date | 04/13/2007
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Last Update Date | 11/24/2010
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Provider Practice Location Address
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Address Line | 6225 W TOUHY AVE
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City | CHICAGO
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State | IL
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Zip | 60646-1105
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Country | US
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Telephone | 773-775-7540
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Fax |
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Provider Business Mailing Address
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Address Line | 5015 N PAULINA ST SUITE 325
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City | CHICAGO
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State | IL
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Zip | 60640-2756
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Country | US
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Telephone | 773-775-7540
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Fax |
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Authorized Official
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Title or Position | CEO AND MEDICAL DIRECTOR
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Name | DR. JOSE L. MEDINA
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Credential | MD
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Telephone | 773-775-7540
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 036048770
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License Number State | IL
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