1609120138 NPI number — PHYSICIAN URGENT CARE OF ILLINOIS, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609120138 NPI number — PHYSICIAN URGENT CARE OF ILLINOIS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIAN URGENT CARE OF ILLINOIS, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609120138
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4941 N KEDZIE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60625-5009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-309-6714
Provider Business Mailing Address Fax Number:
773-309-6298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1554 TODD FARM DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELGIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60123-1287
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-888-7423
Provider Business Practice Location Address Fax Number:
847-841-7285
Provider Enumeration Date:
11/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
RUSTOM
Authorized Official First Name:
NASER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-237-3500

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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