Provider Demographics
NPI:1720154396
Name:ANDREW J KONTRICK MDSC
Entity Type:Organization
Organization Name:ANDREW J KONTRICK MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER SERVICE CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:KONTRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-244-5884
Mailing Address - Street 1:35 TOWER COURT
Mailing Address - Street 2:SUITE I
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5712
Mailing Address - Country:US
Mailing Address - Phone:847-244-5884
Mailing Address - Fax:847-244-0547
Practice Address - Street 1:35 TOWER COURT
Practice Address - Street 2:SUITE I
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5712
Practice Address - Country:US
Practice Address - Phone:847-244-5884
Practice Address - Fax:847-244-0547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
04926221OtherBCBS
IL03604585865Medicaid
C51269Medicare UPIN
789860Medicare ID - Type Unspecified