Provider Demographics
NPI:1013089481
Name:NORTHWEST SUBURBAN UROLOGY ASSOCIATES SC
Entity Type:Organization
Organization Name:NORTHWEST SUBURBAN UROLOGY ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:JEROME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-871-4772
Mailing Address - Street 1:800 BIESTERFIELD RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-7312
Mailing Address - Country:US
Mailing Address - Phone:847-593-0404
Mailing Address - Fax:847-593-1509
Practice Address - Street 1:800 BIESTERFIELD RD
Practice Address - Street 2:SUITE 303
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-7312
Practice Address - Country:US
Practice Address - Phone:847-593-0404
Practice Address - Fax:847-593-1509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL946350OtherPTAN