Healthcare Provider Details

I. General information

NPI: 1417131632
Provider Name (Legal Business Name): HECTOR A. RUIZ C.S.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 12/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 N CICERO AVE 4TH FLOOR
CHICAGO IL
60641-1651
US

IV. Provider business mailing address

4211 N CICERO AVE 4TH FLOOR
CHICAGO IL
60641-1651
US

V. Phone/Fax

Practice location:
  • Phone: 773-545-6900
  • Fax: 773-545-2220
Mailing address:
  • Phone: 773-545-6900
  • Fax: 773-545-2220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number03-177
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: