Provider First Line Business Practice Location Address:
840 SOUTH WOOD STREET
Provider Second Line Business Practice Location Address:
ROOM 402, CLINICAL SCIENCES BUILDING, MAIL CODE 958
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:
312-355-0104
Provider Business Practice Location Address Fax Number:
312-413-3483
Provider Enumeration Date:
05/19/2025