Provider Demographics
NPI:1033154786
Name:SKYLINE NEUROSCIENCE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:SKYLINE NEUROSCIENCE ASSOCIATES, LLC
Other - Org Name:WAUKEGAN CLINIC CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7630
Mailing Address - Street 1:2000 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4525
Mailing Address - Country:US
Mailing Address - Phone:615-860-1351
Mailing Address - Fax:866-831-4898
Practice Address - Street 1:3443 DICKERSON PIKE STE 580
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37207-2526
Practice Address - Country:US
Practice Address - Phone:615-860-1351
Practice Address - Fax:615-860-1242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361431792084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1306937289Medicaid
IL036143179Medicaid
IL204872623Medicaid