Basic Information
| Provider Information | |||||||||
| NPI: | 1831115583 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN ILLINOIS AMBULATORY SERVICE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1121 LAKE COOK ROAD | ||||||||
| Address2: | SUITE M | ||||||||
| City: | DEERFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600155234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479454550 | ||||||||
| FaxNumber: | 8479488103 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 MCHENRY RD. | ||||||||
| Address2: | |||||||||
| City: | BUFFALO GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600896740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478219050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KONOWITZ | ||||||||
| AuthorizedOfficialFirstName: | HOWARD | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8479219733 | ||||||||
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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 | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.