Provider Demographics
NPI:1851489751
Name:NORTHWEST UROLOGICAL ASSOCIATES, S.C.
Entity Type:Organization
Organization Name:NORTHWEST UROLOGICAL ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:NELLESSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-439-4343
Mailing Address - Street 1:2101 S ARLINGTON HEIGHTS RD
Mailing Address - Street 2:#108
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-4185
Mailing Address - Country:US
Mailing Address - Phone:847-439-4343
Mailing Address - Fax:847-439-4510
Practice Address - Street 1:2101 S ARLINGTON HEIGHTS RD
Practice Address - Street 2:#108
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-4185
Practice Address - Country:US
Practice Address - Phone:847-439-4343
Practice Address - Fax:847-439-4510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
603080Medicare ID - Type Unspecified