Healthcare Provider Details

I. General information

NPI: 1952633836
Provider Name (Legal Business Name): MIDWEST CYGNETAZURE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1474 MERCHANT DR
ALGONQUIN IL
60102-5917
US

IV. Provider business mailing address

1474 MERCHANT DR
ALGONQUIN IL
60102-5917
US

V. Phone/Fax

Practice location:
  • Phone: 847-458-0625
  • Fax: 847-458-8822
Mailing address:
  • Phone: 847-458-0625
  • Fax: 847-458-8822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. GUDRUN VIGDIS JONSDOTTIR
Title or Position: PRESIDENT
Credential:
Phone: 847-458-0625