Provider Demographics
NPI:1053462499
Name:NORTH SHORE VASCULAR ASSOCIATES LTD
Entity Type:Organization
Organization Name:NORTH SHORE VASCULAR ASSOCIATES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:GOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-441-2700
Mailing Address - Street 1:495 CENTRAL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3044
Mailing Address - Country:US
Mailing Address - Phone:847-441-2700
Mailing Address - Fax:847-441-9955
Practice Address - Street 1:495 CENTRAL AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3044
Practice Address - Country:US
Practice Address - Phone:847-441-2700
Practice Address - Fax:847-441-9955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212082Medicare ID - Type UnspecifiedPROVIDER NUMBER