Provider First Line Business Practice Location Address:
2121 W TAYLOR ST
Provider Second Line Business Practice Location Address:
SPH/EOHS, OCC. MED., MC 684
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-4224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-413-0369
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2006