Provider Demographics
NPI:1477611028
Name:WOMENS SPECIALTY CARE SC
Entity Type:Organization
Organization Name:WOMENS SPECIALTY CARE SC
Other - Org Name:MASS MEDICAL IMAGING
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-295-0433
Mailing Address - Street 1:475 MCCORMICK DR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-3349
Mailing Address - Country:US
Mailing Address - Phone:847-295-0433
Mailing Address - Fax:847-295-0439
Practice Address - Street 1:840 S WAUKEGAN RD STE 208
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-2619
Practice Address - Country:US
Practice Address - Phone:847-295-0433
Practice Address - Fax:847-234-0034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093085207V00000X
261QR0200X, 261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
E87911Medicare UPIN
212097Medicare ID - Type Unspecified