Healthcare Provider Details

I. General information

NPI: 1053597161
Provider Name (Legal Business Name): 1800 MCDONOUGH ROAD SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2008
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 MCDONOUGH RD SUITE 100
HOFFMAN ESTATES IL
60192-4566
US

IV. Provider business mailing address

2607 W 22ND ST SUITE 48
OAK BROOK IL
60523-1231
US

V. Phone/Fax

Practice location:
  • Phone: 847-742-7272
  • Fax:
Mailing address:
  • Phone: 630-990-7770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number7003116
License Number StateIL

VIII. Authorized Official

Name: KIANOOSH JAFARI
Title or Position: OWNER
Credential: M.D.
Phone: 630-990-7770