Healthcare Provider Details

I. General information

NPI: 1376457689
Provider Name (Legal Business Name): FORTIS SURGICAL SULLIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 N YORK ST # 145
ELMHURST IL
60126-1620
US

IV. Provider business mailing address

627 N YORK ST # 145
ELMHURST IL
60126-1620
US

V. Phone/Fax

Practice location:
  • Phone: 346-771-1189
  • Fax:
Mailing address:
  • Phone: 346-771-1189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: BARKATH AFROZ KHAN
Title or Position: CLINIC/CENTER
Credential:
Phone: 34-677-1118