Provider Demographics
NPI:1225386972
Name:NORTH SHORE PHYSICAL MEDICAL GROUP, SC
Entity Type:Organization
Organization Name:NORTH SHORE PHYSICAL MEDICAL GROUP, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:DUZEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-367-4900
Mailing Address - Street 1:1117 S MILWAUKEE AVE
Mailing Address - Street 2:SUITE D-7
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3798
Mailing Address - Country:US
Mailing Address - Phone:847-367-4900
Mailing Address - Fax:847-367-4904
Practice Address - Street 1:1117 S MILWAUKEE AVE
Practice Address - Street 2:SUITE D-7
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3798
Practice Address - Country:US
Practice Address - Phone:847-367-4900
Practice Address - Fax:847-367-4904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067064207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty