Healthcare Provider Details

I. General information

NPI: 1588805675
Provider Name (Legal Business Name): GOUNDER CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2009
Last Update Date: 03/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3347 N CLARK ST UNIT C
CHICAGO IL
60657-1149
US

IV. Provider business mailing address

3347 N CLARK ST UNIT C
CHICAGO IL
60657-1149
US

V. Phone/Fax

Practice location:
  • Phone: 773-698-8552
  • Fax:
Mailing address:
  • Phone: 773-698-8552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36109397
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. STEPHANIE GOUNDER
Title or Position: MANAGER
Credential:
Phone: 773-698-8552