Provider Demographics
NPI:1992980627
Name:PHILIP H SHERIDAN JR SC
Entity type:Organization
Organization Name:PHILIP H SHERIDAN JR SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:H
Authorized Official - Last Name:SHERIDAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:847-774-7836
Mailing Address - Street 1:PO BOX 616
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-0616
Mailing Address - Country:US
Mailing Address - Phone:708-366-7177
Mailing Address - Fax:708-366-3301
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:847-657-1960
Practice Address - Fax:847-446-1893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079226207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216062OtherMEDICARE
IL01637916OtherBLUE CROSS BLUE SHIELD
IL036079226Medicaid
ILE94399Medicare UPIN