Provider Demographics
NPI:1639482235
Name:YOUR MEDICOS SC
Entity Type:Organization
Organization Name:YOUR MEDICOS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NIKITA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVKAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-850-5882
Mailing Address - Street 1:1300 BUSCH PKWY
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-4505
Mailing Address - Country:US
Mailing Address - Phone:847-850-5882
Mailing Address - Fax:847-850-5892
Practice Address - Street 1:1300 BUSCH PKWY
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-4505
Practice Address - Country:US
Practice Address - Phone:847-850-5882
Practice Address - Fax:847-850-5892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-23
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010683111N00000X
IL036074991261QA1903X, 261QM1300X, 261QP2000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4830Medicare PIN