Healthcare Provider Details

I. General information

NPI: 1871899328
Provider Name (Legal Business Name): SOUTH PULASKI SURGICAL, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6224 S PULASKI RD
CHICAGO IL
60629-4610
US

IV. Provider business mailing address

6224 S PULASKI RD
CHICAGO IL
60629-4610
US

V. Phone/Fax

Practice location:
  • Phone: 773-735-8200
  • Fax:
Mailing address:
  • Phone: 773-735-8200
  • 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: DR. MARK COHEN
Title or Position: PRESIDENT
Credential: DC
Phone: 773-735-8200