Basic Information
| Provider Information | |||||||||
| NPI: | 1013155167 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHSHORE UNIVERSITY HEALTHSYSTEM FACULTY PRACTICE ASSOCIATES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KNOX PAIN CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9701 KNOX AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600761256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479336974 | ||||||||
| FaxNumber: | 8479336044 | ||||||||
| Practice Location | |||||||||
| Address1: | 9701 KNOX AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600761256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479336974 | ||||||||
| FaxNumber: | 8479336044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2009 | ||||||||
| LastUpdateDate: | 05/11/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOLBUS | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8475702503 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 0000646 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | DC2634 | 01 | IL | RAILROAD | OTHER | 01623422 | 01 | IL | BCBS | OTHER |