Basic Information
| Provider Information | |||||||||
| NPI: | 1528079977 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEURODIAGNOSTIC SERVICES LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 OAKMONT LN | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307892550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2310 YORK ST | ||||||||
| Address2: | #2C | ||||||||
| City: | BLUE ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604062411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083884902 | ||||||||
| FaxNumber: | 7083880043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 07/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | STEPHENS | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7083884902 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 031603006 | 01 | IL | BCBS PROVIDER ID | OTHER | CL0157 | 01 | IL | RAIL ROAD MEDICARE | OTHER | 131781400 | 01 | IL | ACS HEALTHNET | OTHER |