MEDICARE: NOVAMED SURGERY CENTER OF CHICAGO-NORTHSHORE, 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	261QA1903X	Ambulatory Surgical Clinic/Center	7002678	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00012000	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992709851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVAMED SURGERY CENTER OF CHICAGO-NORTHSHORE, LLC

Provider Business Mailing Address
First Line	:	3034 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-3729
Country	:	US
Telephone Number	:	773-973-7432
Fax Number	:

Provider Business Practice Location Address
First Line	:	3034 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-3729
Country	:	US
Telephone Number	:	773-973-7432
Fax Number	:	773-973-1119

Authorized Official
Title or Position	:	OFFICER AND AUTHORIZED OFFICIAL
Name	:	JENNIFER BOYD BALDOCK
Credential	:
Telephone Number	:	615-234-5900

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	05/11/2021

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