Provider Demographics
NPI:1316983315
Name:NORTH SHORE SPORTS MEDICINE AND ORTHOPAEDIC CENTER, LTD.
Entity type:Organization
Organization Name:NORTH SHORE SPORTS MEDICINE AND ORTHOPAEDIC CENTER, LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHADWICK
Authorized Official - Middle Name:
Authorized Official - Last Name:PRODROMOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-699-6810
Mailing Address - Street 1:1714 MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-1441
Mailing Address - Country:US
Mailing Address - Phone:847-688-6810
Mailing Address - Fax:847-699-2854
Practice Address - Street 1:1714 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-1441
Practice Address - Country:US
Practice Address - Phone:847-699-6810
Practice Address - Fax:847-699-2854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL131650500OtherOWCP FOR DEPT OF LABOR
IL1618365OtherBC/BS
IL200030424OtherRAILROAD MEDICARE
IL200030424OtherRAILROAD MEDICARE
IL209723Medicare ID - Type Unspecified