Provider Demographics
NPI:1194930644
Name:NORTH SHORE MEDICAL SERVICES
Entity type:Organization
Organization Name:NORTH SHORE MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-433-3060
Mailing Address - Street 1:480 ELM PLACE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2538
Mailing Address - Country:US
Mailing Address - Phone:847-433-3060
Mailing Address - Fax:847-433-6325
Practice Address - Street 1:480 ELM PL
Practice Address - Street 2:SUITE 200
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2538
Practice Address - Country:US
Practice Address - Phone:847-433-3060
Practice Address - Fax:847-433-6325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042006963174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202614Medicare ID - Type Unspecified