Healthcare Provider Details

I. General information

NPI: 1003340415
Provider Name (Legal Business Name): KM WILLIAMS MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST STE 910
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

3949 S ELLIS AVE
CHICAGO IL
60653-2419
US

V. Phone/Fax

Practice location:
  • Phone: 312-622-7320
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number038.118717
License Number StateIL

VIII. Authorized Official

Name: DR. KENYA M WILLIAMS
Title or Position: PRESIDENT
Credential: MD
Phone: 312-622-7320