Healthcare Provider Details

I. General information

NPI: 1114558145
Provider Name (Legal Business Name): HOSSAM NADER ABDEL AZIZ RSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 S MICHIGAN AVE
CHICAGO IL
60616-2315
US

IV. Provider business mailing address

6016 MARSHALL AVE
CHICAGO RIDGE IL
60415-1606
US

V. Phone/Fax

Practice location:
  • Phone: 312-567-2000
  • Fax:
Mailing address:
  • Phone: 708-336-1948
  • Fax: 708-634-3437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number238.000650
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: