Healthcare Provider Details

I. General information

NPI: 1225068240
Provider Name (Legal Business Name): RICHARD A KASUFKIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 06/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7230 W NORTH AVE STE 106B RESURRECTION IMMEDIATE CARE CENTER
ELMWOOD PARK IL
60707-4262
US

IV. Provider business mailing address

7230 W NORTH AVE STE 106B RESURRECTION IMMEDIATE CARE CENTER
CHICAGO IL
60707-4262
US

V. Phone/Fax

Practice location:
  • Phone: 708-453-3000
  • Fax: 708-453-4660
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036103195
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: