Healthcare Provider Details

I. General information

NPI: 1790710390
Provider Name (Legal Business Name): SOUTHWESTERN MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7456 S STATE RD, STE 300 THIRD FLOOR
BEDFORD PARK IL
60638-6621
US

IV. Provider business mailing address

PO BOX 88724
CAROL STREAM IL
60188-8724
US

V. Phone/Fax

Practice location:
  • Phone: 773-445-9696
  • Fax: 773-445-9590
Mailing address:
  • Phone: 773-445-9696
  • Fax: 773-445-9590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number7002264
License Number StateIL

VIII. Authorized Official

Name: KENNY BOZORGI
Title or Position: CEO
Credential: MD
Phone: 773-445-9696