Provider Demographics
NPI:1639343049
Name:THE MEDICAL & SURGICAL CENTER OF ILLINOIS
Entity Type:Organization
Organization Name:THE MEDICAL & SURGICAL CENTER OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:POTACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-808-3338
Mailing Address - Street 1:3818 NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3818 NOTTINGHAM DR
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-5240
Practice Address - Country:US
Practice Address - Phone:847-808-3338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
T38897Medicare UPIN