Provider Demographics
NPI:1659425726
Name:NORTH SHORE MEDICAL SUPPLIES CO
Entity Type:Organization
Organization Name:NORTH SHORE MEDICAL SUPPLIES CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAFAT
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-262-4432
Mailing Address - Street 1:7455 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1735
Mailing Address - Country:US
Mailing Address - Phone:773-262-4432
Mailing Address - Fax:773-262-4712
Practice Address - Street 1:7455 NORTH WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645
Practice Address - Country:US
Practice Address - Phone:773-262-4432
Practice Address - Fax:773-262-4712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203000319332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001633212OtherBCBS
IL=========001Medicaid
IL0001633212OtherBCBS