Provider Demographics
NPI:1902218209
Name:BERROW, SUPERMAN DAVID (MS, ATC, CES)
Entity Type:Individual
Prefix:
First Name:SUPERMAN
Middle Name:DAVID
Last Name:BERROW
Suffix:
Gender:M
Credentials:MS, ATC, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 W NORTH AVE APT 2F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5237
Mailing Address - Country:US
Mailing Address - Phone:859-489-7645
Mailing Address - Fax:
Practice Address - Street 1:1920 N FOOTBALL DR
Practice Address - Street 2:HALAS HALL
Practice Address - City:LAKEFOREST
Practice Address - State:IL
Practice Address - Zip Code:60045
Practice Address - Country:US
Practice Address - Phone:847-528-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096003014174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist