Provider First Line Business Practice Location Address:
1901 WEST HARRISON
Provider Second Line Business Practice Location Address:
FANTUS/ASC
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-864-0706
Provider Business Practice Location Address Fax Number:
312-689-3258
Provider Enumeration Date:
03/21/2007