Healthcare Provider Details

I. General information

NPI: 1114063989
Provider Name (Legal Business Name): GAJDA SPORTS MEDICAL CENTER LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 LAKE COOK ROAD SUITE 200C
DEERFIELD IL
60015
US

IV. Provider business mailing address

521 MALDEN AVE
LA GRANGE PARK IL
60526-5514
US

V. Phone/Fax

Practice location:
  • Phone: 708-352-2392
  • Fax: 708-352-2738
Mailing address:
  • Phone: 708-352-2392
  • Fax: 708-352-2738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number036066049
License Number StateIL

VIII. Authorized Official

Name: KAREN DALE GAJDA
Title or Position: OWNER DOCTOR
Credential: DO
Phone: 708-352-2392