Provider Demographics
NPI:1275645590
Name:MICHAEL J VERTA JR, MDSC
Entity Type:Organization
Organization Name:MICHAEL J VERTA JR, MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:VERTA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:847-205-0050
Mailing Address - Street 1:321 RALEIGH RD
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60043-1253
Mailing Address - Country:US
Mailing Address - Phone:847-205-0050
Mailing Address - Fax:847-256-2931
Practice Address - Street 1:1000 CENTRAL ST
Practice Address - Street 2:SUITE 800
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1777
Practice Address - Country:US
Practice Address - Phone:847-205-0050
Practice Address - Fax:847-256-2931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
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
IL21607920OtherBCBS OF IL
IL498770Medicare ID - Type Unspecified
IL21607920OtherBCBS OF IL