Provider Demographics
NPI:1306036819
Name:NORTHSHORE MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:NORTHSHORE MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PLEBANOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-279-7963
Mailing Address - Street 1:1300 BUSCH PKWY
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-4505
Mailing Address - Country:US
Mailing Address - Phone:847-850-5882
Mailing Address - Fax:847-850-5892
Practice Address - Street 1:1300 BUSCH PKWY
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-4505
Practice Address - Country:US
Practice Address - Phone:847-850-5882
Practice Address - Fax:847-850-5892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4476Medicare PIN