Basic Information
| Provider Information | |||||||||
| NPI: | 1619961927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRESLOW | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 RAND RD STE 300 | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600162359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473753000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9000 WAUKEGAN RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MORTON GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600532127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473753000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 036-104096 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 036-104096 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.