=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588078844
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFEFORCE MEDICAL INSTITUTE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2014
-----------------------------------------------------
Last Update Date | 06/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 REVERE DR SITE 820
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-1563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-563-4493
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 60 REVERE DR SITE 820
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-1563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-563-4493
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARK ROSENBLOOM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 847-563-4493
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083P0901X
-----------------------------------------------------
Taxonomy Name | Public Health & General Preventive Medicine Physician
-----------------------------------------------------
License Number | 336047254
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------