MEDICARE: NORTHERN STAR MGMT INC

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1699092494
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN STAR MGMT INC

Provider Business Mailing Address
First Line	:	1755 PARK ST
Second Line	:	SUITE 200
City	:	NAPERVILLE
State	:	IL
Zip	:	60563-4861
Country	:	US
Telephone Number	:	630-778-6617
Fax Number	:

Provider Business Practice Location Address
First Line	:	1755 PARK ST
Second Line	:	SUITE 200
City	:	NAPERVILLE
State	:	IL
Zip	:	60563-4861
Country	:	US
Telephone Number	:	630-778-6617
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT / OWNER
Name	:	OTABEK FAYZIYEV
Credential	:
Telephone Number	:	630-778-6617

Provider Enumeration Date	:	05/03/2010
Last Update Date	:	05/03/2010

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