Basic Information
| Provider Information | |||||||||
| NPI: | 1427094077 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST NEUROLOGY, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22285 N PEPPER RD | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | LAKE BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600102538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478826604 | ||||||||
| FaxNumber: | 8478826228 | ||||||||
| Practice Location | |||||||||
| Address1: | 22285 N PEPPER RD | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | LAKE BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600102538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478826604 | ||||||||
| FaxNumber: | 8478826228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 06/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | SHERMAN | ||||||||
| AuthorizedOfficialFirstName: | SANFORD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8478826604 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 042005757 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 698600 | 01 | IL | MEDICARE PTAN | OTHER |