Healthcare Provider Details

I. General information

NPI: 1093850331
Provider Name (Legal Business Name): LAPAROSCOPY INTERNATIONAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3714 W 26TH ST
CHICAGO IL
60623-3824
US

IV. Provider business mailing address

4333 MAIN ST
DOWNERS GROVE IL
60515-2869
US

V. Phone/Fax

Practice location:
  • Phone: 630-810-0212
  • Fax: 630-810-1027
Mailing address:
  • Phone: 630-810-0212
  • Fax: 630-810-1027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036050637
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036050637
License Number StateIL

VIII. Authorized Official

Name: MRS. KRISTINA L BUTLER
Title or Position: BILLING MANAGER
Credential:
Phone: 630-810-1219