=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902034374
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVATIVE DOCTOR GROUP LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2009
-----------------------------------------------------
Last Update Date | 06/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 W 35TH STREET 11TH FLOOR
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-532-3580
-----------------------------------------------------
Fax | 773-238-9782
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2025 S ARLINGTON HEIGHTS ROAD SUITE #105
-----------------------------------------------------
City | ARLINGTON HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60005-4152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-437-2300
-----------------------------------------------------
Fax | 847-437-7144
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | DR. ALBERT P KNOTT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 847-437-2300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------