Provider Demographics
NPI:1508141441
Name:NORTH SHORE UNIVERSITY HEALTH SYSTEM
Entity Type:Organization
Organization Name:NORTH SHORE UNIVERSITY HEALTH SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:ICAYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-570-2509
Mailing Address - Street 1:9744 DEE RD
Mailing Address - Street 2:APT # 402
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1768
Mailing Address - Country:US
Mailing Address - Phone:630-842-0067
Mailing Address - Fax:
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:847-570-2509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF CHICAGO PRITZKER SCHOOL OF MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125057831207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty