Provider Demographics
NPI:1558643734
Name:NORTHWESTERN ORAL & MAXILLOFACIAL SURGEONS PC
Entity Type:Organization
Organization Name:NORTHWESTERN ORAL & MAXILLOFACIAL SURGEONS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:B
Authorized Official - Last Name:OLSSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-926-6333
Mailing Address - Street 1:201 E HURON ST
Mailing Address - Street 2:SUITE 12-100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3197
Mailing Address - Country:US
Mailing Address - Phone:312-926-6333
Mailing Address - Fax:312-926-3444
Practice Address - Street 1:201 E HURON ST
Practice Address - Street 2:SUITE 12-100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3197
Practice Address - Country:US
Practice Address - Phone:312-926-6333
Practice Address - Fax:312-926-3444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.001615261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
986840Medicare PIN
U34928Medicare UPIN