Provider Demographics
NPI:1962491472
Name:PARKSIDE OBSTETRICS & GYNECOLOGY SC
Entity Type:Organization
Organization Name:PARKSIDE OBSTETRICS & GYNECOLOGY SC
Other - Org Name:PARKSIDE OBSTETRICS GYNCEOLOGY & INFERTILITY SC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-825-1100
Mailing Address - Street 1:1875 DEMPSTER ST
Mailing Address - Street 2:SUITE 465
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1186
Mailing Address - Country:US
Mailing Address - Phone:847-825-1100
Mailing Address - Fax:847-825-0994
Practice Address - Street 1:1875 DEMPSTER ST
Practice Address - Street 2:SUITE 465
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1186
Practice Address - Country:US
Practice Address - Phone:847-825-1100
Practice Address - Fax:847-825-0994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL50108OtherADVOCATE
IL01617935OtherBLUE SHIELD
IL966440Medicare PIN