Healthcare Provider Details

I. General information

NPI: 1851456909
Provider Name (Legal Business Name): FULLERTON MEDICAL SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5723 W FULLERTON AVE
CHICAGO IL
60639-2306
US

IV. Provider business mailing address

5723 W FULLERTON AVE
CHICAGO IL
60639-2306
US

V. Phone/Fax

Practice location:
  • Phone: 773-622-8060
  • Fax: 773-622-8095
Mailing address:
  • Phone: 773-622-8060
  • Fax: 773-622-8095

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: DR. SAMUEL RAMIREZ
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 773-622-8060