MEDICARE: INTEGRATED CHIROPRACTIC OF THE NORTH SHORE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	038-009467	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01628196	OTHER	IL	BCBSIL

General Provider Information

NPI Number	:	1639148307
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED CHIROPRACTIC OF THE NORTH SHORE LLC

Provider Business Mailing Address
First Line	:	666 DUNDEE RD
Second Line	:	SUITE 307
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-2727
Country	:	US
Telephone Number	:	847-897-8888
Fax Number	:

Provider Business Practice Location Address
First Line	:	666 DUNDEE RD
Second Line	:	SUITE 307
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-2727
Country	:	US
Telephone Number	:	847-897-8888
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARK GRUMET
Credential	:	DC
Telephone Number	:	847-897-8888

Provider Enumeration Date	:	03/15/2006
Last Update Date	:	01/22/2013

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