Healthcare Provider Details

I. General information

NPI: 1255435509
Provider Name (Legal Business Name): JUSTINE MEDICAL ASSOCIATES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 W 87TH STREET
CHICAGO IL
60620-4819
US

IV. Provider business mailing address

1524 W 87TH STREET
CHICAGO IL
60620-4819
US

V. Phone/Fax

Practice location:
  • Phone: 773-779-1586
  • Fax: 773-779-5430
Mailing address:
  • Phone: 773-779-1586
  • Fax: 773-779-5430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: GULAM A HAJAT
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 773-779-1586