Healthcare Provider Details

I. General information

NPI: 1487115804
Provider Name (Legal Business Name): ONTARIO STREET OPERATORY FAC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 W ONTARIO STREET OPERATORY
CHICAGO IL
60654
US

IV. Provider business mailing address

22 W ONTARIO STREET OPERATORY
CHICAGO IL
60654
US

V. Phone/Fax

Practice location:
  • Phone: 312-642-0400
  • Fax:
Mailing address:
  • Phone: 312-642-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JEFFREY WEINZWEIG
Title or Position: OWNER
Credential: MD
Phone: 312-642-0400