Healthcare Provider Details

I. General information

NPI: 1275918112
Provider Name (Legal Business Name): AVANT -GARDE MEDICNE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W WASHINGTON ST APT 5006
CHICAGO IL
60606-3543
US

IV. Provider business mailing address

1401 S CALIFORNIA AVE
CHICAGO IL
60608-1858
US

V. Phone/Fax

Practice location:
  • Phone: 702-566-5343
  • Fax:
Mailing address:
  • Phone: 773-522-2010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036-111103
License Number StateIL

VIII. Authorized Official

Name: DR. DEEPTHI S SAXENA
Title or Position: OWNER
Credential: M.D.
Phone: 702-566-4343