Healthcare Provider Details

I. General information

NPI: 1699008706
Provider Name (Legal Business Name): S. O. GROUP, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W. HARRISON STREET SUITE 409
CHICAGO IL
60612
US

IV. Provider business mailing address

1725 W. HARRISON STREET SUITE 409
CHICAGO IL
60612
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-2302
  • Fax: 312-563-2228
Mailing address:
  • Phone: 312-942-2302
  • Fax: 312-563-2228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number042.006019
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number042.006019
License Number StateIL

VIII. Authorized Official

Name: THOMAS R. WITT
Title or Position: PRESIDENT
Credential: MD
Phone: 312-942-2302