Healthcare Provider Details

I. General information

NPI: 1780674515
Provider Name (Legal Business Name): ASSOCIATES IN HEAD & NECK SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST SUITE 938
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

PO BOX 9
MATTESON IL
60443-0009
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-2175
  • Fax: 312-942-2052
Mailing address:
  • Phone: 708-747-5850
  • Fax: 708-747-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State

VIII. Authorized Official

Name: THOMAS J NIELSEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 312-942-2175