Basic Information
Provider Information | |||||||||
NPI: | 1962686691 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SURGICAL NEUROLOGY ASSOCIATES LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 880 W CENTRAL RD | ||||||||
Address2: | SUITE 6100 | ||||||||
City: | ARLINGTON HTS | ||||||||
State: | IL | ||||||||
PostalCode: | 600052355 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8473986464 | ||||||||
FaxNumber: | 8473987961 | ||||||||
Practice Location | |||||||||
Address1: | 1732 W ALGONQUIN RD | ||||||||
Address2: |   | ||||||||
City: | ARLINGTON HTS | ||||||||
State: | IL | ||||||||
PostalCode: | 600053405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476371166 | ||||||||
FaxNumber: | 8476371167 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/17/2007 | ||||||||
LastUpdateDate: | 12/17/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POTTER | ||||||||
AuthorizedOfficialFirstName: | SUSIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8473986464 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.