Provider Demographics
NPI:1942281126
Name:AMERICAN CENTER FOR SPINE & NEUROSURGERY LLC
Entity Type:Organization
Organization Name:AMERICAN CENTER FOR SPINE & NEUROSURGERY LLC
Other - Org Name:LAKE COUNTY NEUROSURGERY LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:CITOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-362-1848
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:847-362-3351
Practice Address - Street 1:712 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3279
Practice Address - Country:US
Practice Address - Phone:847-362-1848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2012-02-08
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
IL5474340001Medicare NSC
IL209425Medicare PIN