Provider Demographics
NPI:1710296934
Name:NORTHSIDE NEUROSURGERY, LLC
Entity Type:Organization
Organization Name:NORTHSIDE NEUROSURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-990-1463
Mailing Address - Street 1:712 S MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3279
Mailing Address - Country:US
Mailing Address - Phone:847-362-1848
Mailing Address - Fax:847-362-2588
Practice Address - Street 1:3000 N HALSTED ST
Practice Address - Street 2:SUITE 605
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5188
Practice Address - Country:US
Practice Address - Phone:773-348-4333
Practice Address - Fax:773-348-2434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4917Medicare PIN