Healthcare Provider Details

I. General information

NPI: 1588656037
Provider Name (Legal Business Name): HYDE PARK MEDICAL SPECIALTY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1644 E 53RD ST
CHICAGO IL
60615-4210
US

IV. Provider business mailing address

9933 S WESTERN AVE SUITE 102
CHICAGO IL
60643-1810
US

V. Phone/Fax

Practice location:
  • Phone: 773-752-2111
  • Fax: 773-752-6703
Mailing address:
  • Phone: 773-233-3800
  • Fax: 773-233-2513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. FORTUNEE MASSUDA
Title or Position: MEDICAL DIRECTOR/CEO
Credential: DPM
Phone: 773-752-2111