Healthcare Provider Details

I. General information

NPI: 1861684458
Provider Name (Legal Business Name): HISPANIC AMERICAN ENDOSCOPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 04/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3536 W FULLERTON AVE
CHICAGO IL
60647-2443
US

IV. Provider business mailing address

3536 W FULLERTON AVE
CHICAGO IL
60647-2443
US

V. Phone/Fax

Practice location:
  • Phone: 773-772-1212
  • Fax: 773-697-8305
Mailing address:
  • Phone: 312-761-0100
  • Fax: 773-697-8305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number7003126
License Number StateIL

VIII. Authorized Official

Name: DR. RYAN ROSENTHAL
Title or Position: OWNER
Credential: DC
Phone: 312-761-0100