Healthcare Provider Details

I. General information

NPI: 1477324754
Provider Name (Legal Business Name): LUIS EDUARDO CRUZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N CICERO AVE
CHICAGO IL
60641-5106
US

IV. Provider business mailing address

6621 APPLETREE ST
HANOVER PARK IL
60133-3901
US

V. Phone/Fax

Practice location:
  • Phone: 248-336-4000
  • Fax: 248-336-9137
Mailing address:
  • Phone: 630-618-0491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: