Provider Demographics
NPI:1104087873
Name:NORTH SIDE NEUROLOGY SC
Entity type:Organization
Organization Name:NORTH SIDE NEUROLOGY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:V
Authorized Official - Last Name:CABIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-236-0512
Mailing Address - Street 1:PO BOX 1528
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-6008
Mailing Address - Country:US
Mailing Address - Phone:847-236-0512
Mailing Address - Fax:
Practice Address - Street 1:5600 W ADDISON ST
Practice Address - Street 2:SUITE 400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4401
Practice Address - Country:US
Practice Address - Phone:847-236-0512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360444682084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6001501Medicaid