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General NPI Number Information
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NPI Number | 1548308364
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Entity Type | Organization
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Legal Business Name | NORTHSHORE MEDICAL PRACTICE LTD
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Dates
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Enumeration Date | 02/02/2007
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Last Update Date | 03/21/2017
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Provider Practice Location Address
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Address Line | 92 RIVERSIDE DR
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City | DEERFIELD
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State | IL
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Zip | 60015-4868
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Country | US
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Telephone | 847-573-9006
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Fax | 847-940-0843
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Provider Business Mailing Address
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Address Line | 870 W END CT STE 202
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City | VERNON HILLS
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State | IL
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Zip | 60061-1378
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Country | US
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Telephone | 847-573-9006
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Fax | 847-940-0843
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Authorized Official
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Title or Position | OWNER
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Name | DR. FANAN NIJIN FALOUJI
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Credential | MD
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Telephone | 847-573-9006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 036096519
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License Number State | IL
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