Provider Demographics
NPI:1558710822
Name:NORTHSHORE MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:NORTHSHORE MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:OSHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-317-1717
Mailing Address - Street 1:2101 WAUKEGAN RD
Mailing Address - Street 2:104
Mailing Address - City:BANNOCKBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1836
Mailing Address - Country:US
Mailing Address - Phone:847-317-1717
Mailing Address - Fax:847-317-9304
Practice Address - Street 1:2101 WAUKEGAN RD
Practice Address - Street 2:104
Practice Address - City:BANNOCKBURN
Practice Address - State:IL
Practice Address - Zip Code:60015-1836
Practice Address - Country:US
Practice Address - Phone:847-317-1717
Practice Address - Fax:847-317-9304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066116207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC42715Medicare UPIN