Facts
- Status
- A
- Credential
- ATC
- Type
- Individual
- Enumeration date
- 2021-11-09
- Last updated
- 2021-11-09
Licenses
- License IL
- 096003647
Location
- Practice location
- 2300 SHERMER RD
- City
- NORTHBROOK IL
- Postal code
- 600626722
- Phone
- 847-509-2674
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.