Healthcare Provider Details

I. General information

NPI: 1285675678
Provider Name (Legal Business Name): FULLERTON SURGERY CENTER LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 02/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4849 W FULLERTON AVE
CHICAGO IL
60639-2503
US

IV. Provider business mailing address

4849 W FULLERTON AVE
CHICAGO IL
60639-2503
US

V. Phone/Fax

Practice location:
  • Phone: 773-237-2900
  • Fax: 773-622-0769
Mailing address:
  • Phone: 773-237-2900
  • Fax: 773-622-0769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number042618689
License Number StateIL

VIII. Authorized Official

Name: NASER RUSTOM
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: M.D.
Phone: 773-237-2900