Healthcare Provider Details

I. General information

NPI: 1750626081
Provider Name (Legal Business Name): SHAMSHOUN WARDA CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: SAM WARDA CSA

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 03/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5145 N CALIFORNIA AVE
CHICAGO IL
60625-3661
US

IV. Provider business mailing address

2740 W FOSTER AVE STE 310
CHICAGO IL
60625-3547
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-8200
  • Fax: 773-271-5090
Mailing address:
  • Phone: 773-878-8200
  • Fax: 773-293-8804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number238000353
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: