Provider Demographics
NPI:1659563831
Name:NORTH SHORE PRIMARY CARE S.C.
Entity Type:Organization
Organization Name:NORTH SHORE PRIMARY CARE S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-573-9663
Mailing Address - Street 1:1900 HOLLISTER DR STE 250
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5249
Mailing Address - Country:US
Mailing Address - Phone:847-573-9663
Mailing Address - Fax:
Practice Address - Street 1:1900 HOLLISTER DR STE 250
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5249
Practice Address - Country:US
Practice Address - Phone:847-573-9663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101407207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101407Medicaid
IL04932188OtherBCBS PROVIDER ID#
ILH69159OtherUPIN