Healthcare Provider Details

I. General information

NPI: 1508464074
Provider Name (Legal Business Name): METRO NORTH SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2651 N LARAMIE AVE
CHICAGO IL
60639-1613
US

IV. Provider business mailing address

106 N KNIGHT AVE
PARK RIDGE IL
60068-3108
US

V. Phone/Fax

Practice location:
  • Phone: 920-217-6052
  • Fax:
Mailing address:
  • Phone: 920-217-6052
  • 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: JAMIE L VANDENELZEN
Title or Position: OWNER
Credential: DC
Phone: 920-217-6052