Healthcare Provider Details

I. General information

NPI: 1568690899
Provider Name (Legal Business Name): DR. SARGON AUDISHO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4143 N CLAREMONT AVE APT 2
CHICAGO IL
60618-2919
US

IV. Provider business mailing address

890 E HIGGINS RD SUITE 113A
SCHAUMBURG IL
60173-4799
US

V. Phone/Fax

Practice location:
  • Phone: 312-218-1204
  • Fax:
Mailing address:
  • Phone: 224-653-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number036132241
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: