Healthcare Provider Details

I. General information

NPI: 1063831477
Provider Name (Legal Business Name): RUBEN CARDOSO JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 12/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

808 SOUTH WOOD STREET 469 CME, M/C 724
CHICAGO IL
60612
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 312-413-7492
  • Fax: 312-413-0289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036.142999
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: