Basic Information
| Provider Information | |||||||||
| NPI: | 1881975266 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHC OF BUFFALO GROVE DIAGNOSTIC SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PORTRAIT HEALTH CENTERS DIAGNOSTIC SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 W HALF DAY RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | BUFFALO GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600896591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478683435 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 W HALF DAY RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | BUFFALO GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600896591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478683435 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2011 | ||||||||
| LastUpdateDate: | 08/31/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAGGIORE | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8478683435 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TH0100X | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Health Service | 293D00000X | Y | Laboratories | Physiological Laboratory |
No ID Information.