Basic Information
| Provider Information | |||||||||
| NPI: | 1669642997 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH SHORE INTERNAL MEDICINE SPECIALIST, SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 INDUSTRIAL LOOP | ||||||||
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| City: | GREENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531292452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144234100 | ||||||||
| FaxNumber: | 4144234134 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | THIENSVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530921956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622423369 | ||||||||
| FaxNumber: | 2622423219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2008 | ||||||||
| LastUpdateDate: | 03/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | EDALATPOUR | ||||||||
| AuthorizedOfficialFirstName: | MEHRAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2622423369 | ||||||||
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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 | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.