Provider Demographics
NPI:1013155167
Name:NORTHSHORE UNIVERSITY HEALTHSYSTEM FACULTY PRACTICE ASSOCIATES
Entity Type:Organization
Organization Name:NORTHSHORE UNIVERSITY HEALTHSYSTEM FACULTY PRACTICE ASSOCIATES
Other - Org Name:KNOX PAIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLBUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-570-2503
Mailing Address - Street 1:9701 KNOX AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1256
Mailing Address - Country:US
Mailing Address - Phone:847-933-6974
Mailing Address - Fax:847-933-6044
Practice Address - Street 1:9701 KNOX AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1256
Practice Address - Country:US
Practice Address - Phone:847-933-6974
Practice Address - Fax:847-933-6044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-28
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0000646207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDC2634OtherRAILROAD
IL01623422OtherBCBS
IL567850Medicare PIN
IL568510Medicare PIN
IL568500Medicare PIN
IL567840Medicare PIN