Provider Demographics
NPI:1336526219
Name:UNITED SHOCKWAVE SERVICES, LTD.
Entity Type:Organization
Organization Name:UNITED SHOCKWAVE SERVICES, LTD.
Other - Org Name:UNITED THERAPIES
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:NORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-544-5853
Mailing Address - Street 1:PO BOX 95439
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76099-9735
Mailing Address - Country:US
Mailing Address - Phone:877-465-4845
Mailing Address - Fax:847-297-8853
Practice Address - Street 1:120 N LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2040
Practice Address - Country:US
Practice Address - Phone:708-352-6666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNITED SHOCKWAVE SERVICES, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-30
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7003190261QA1903X, 261QL0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QL0400XAmbulatory Health Care FacilitiesClinic/CenterLithotripsy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
ILIL6210Medicare PIN