Provider Demographics
NPI:1003015074
Name:ADVANCED NEUROLOGICAL ASSOCIATES SC
Entity Type:Organization
Organization Name:ADVANCED NEUROLOGICAL ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGELOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:847-716-1302
Mailing Address - Street 1:550 W FRONTAGE RD STE 2745
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-1260
Mailing Address - Country:US
Mailing Address - Phone:847-716-1302
Mailing Address - Fax:847-716-1312
Practice Address - Street 1:550 W FRONTAGE RD STE 2745
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-1260
Practice Address - Country:US
Practice Address - Phone:847-716-1302
Practice Address - Fax:847-716-1312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-088382174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088382Medicaid
IL1630244OtherBLUE CROSS BLUE SHIELD OF
IL388950Medicare PIN
ILG25051Medicare UPIN