Basic Information
| Provider Information | |||||||||
| NPI: | 1801041645 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH SUBURBAN NEPHROLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W 22ND ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605231563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305735000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1425 N HUNT CLUB RD STE 301 | ||||||||
| Address2: | |||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600312639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478559252 | ||||||||
| FaxNumber: | 8478555215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2008 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | GHANTOUS | ||||||||
| AuthorizedOfficialFirstName: | WALID | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8474463200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 01553437 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.