Provider Demographics
NPI:1114964830
Name:NORTH SHORE PHYSICIANS GROUP, LLC
Entity Type:Organization
Organization Name:NORTH SHORE PHYSICIANS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REP
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:CROGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-251-1500
Mailing Address - Street 1:2500 RIDGE AVE
Mailing Address - Street 2:STE 210
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2455
Mailing Address - Country:US
Mailing Address - Phone:847-491-0888
Mailing Address - Fax:
Practice Address - Street 1:2500 RIDGE AVE
Practice Address - Street 2:STE 210
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2455
Practice Address - Country:US
Practice Address - Phone:847-491-0888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213482Medicare PIN