MEDICARE: CHICAGO MEDICAL AND SURGICAL SPECIALISTS, S. C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	036134419	IL
2	202K00000X	Phlebology Physician	036134419	IL

General Provider Information

NPI Number	:	1316310782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO MEDICAL AND SURGICAL SPECIALISTS, S. C.

Provider Business Mailing Address
First Line	:	474 N LAKE SHORE DR
Second Line	:	5206
City	:	CHICAGO
State	:	IL
Zip	:	60611-3400
Country	:	US
Telephone Number	:	317-908-8833
Fax Number	:

Provider Business Practice Location Address
First Line	:	1645 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2543
Country	:	US
Telephone Number	:	224-404-1097
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. SAMSON M. CHAN
Credential	:	M. D.
Telephone Number	:	317-908-8833

Provider Enumeration Date	:	11/07/2015
Last Update Date	:	11/07/2015

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