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General NPI Number Information
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NPI Number | 1912170523
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Entity Type | Organization
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Legal Business Name | LIBERTYVILLE NEUROSURGERY, LLC
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Dates
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Enumeration Date | 04/04/2008
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Last Update Date | 02/06/2012
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Provider Practice Location Address
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Address Line | 712 S MILWAUKEE AVE
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City | LIBERTYVILLE
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State | IL
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Zip | 60048-3279
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Country | US
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Telephone | 847-362-1848
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Fax | 847-362-3351
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Provider Business Mailing Address
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Address Line | 712 S MILWAUKEE AVE
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City | LIBERTYVILLE
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State | IL
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Zip | 60048-3279
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Country | US
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Telephone | 847-362-1848
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Fax | 847-362-3351
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Authorized Official
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Title or Position | OWNER
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Name | JONATHAN S CITOW
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Credential |
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Telephone | 847-362-1848
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207T00000X
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Taxonomy Name | Neurological Surgery Physician
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License Number |
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License Number State |
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