Provider Demographics
NPI:1447429030
Name:B H ADELSON & W GHANTOUS PTR NORTH SUBURBAN NEPHROLOGISTS
Entity Type:Organization
Organization Name:B H ADELSON & W GHANTOUS PTR NORTH SUBURBAN NEPHROLOGISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WALID
Authorized Official - Middle Name:N
Authorized Official - Last Name:GHANTOUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-673-1375
Mailing Address - Street 1:343 RIDGE RD STE A
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3251
Mailing Address - Country:US
Mailing Address - Phone:847-673-1375
Mailing Address - Fax:847-256-3614
Practice Address - Street 1:1445 N HUNT CLUB RD STE 201
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-2603
Practice Address - Country:US
Practice Address - Phone:847-673-1375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL603730Medicare PIN
ILC39546Medicare UPIN
L01225Medicare UPIN
ILL05129Medicare UPIN