Healthcare Provider Details

I. General information

NPI: 1518607696
Provider Name (Legal Business Name): 2001-15 N PARKSIDE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 N WABASH AVE STE P2-A
CHICAGO IL
60611-3744
US

IV. Provider business mailing address

18140 AUDETTE ST
DEARBORN MI
48124-4217
US

V. Phone/Fax

Practice location:
  • Phone: 312-955-4005
  • Fax:
Mailing address:
  • Phone: 312-998-5229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MONA KHAN
Title or Position: PHYSICIAN
Credential: DO
Phone: 312-955-4005