Provider First Line Business Practice Location Address:
1801 W TAYLOR ST STE 2E
Provider Second Line Business Practice Location Address:
MEDICAL STAFF OFFICE
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-4795
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-996-9291
Provider Business Practice Location Address Fax Number:
312-355-4738
Provider Enumeration Date:
05/17/2007