Healthcare Provider Details

I. General information

NPI: 1558920579
Provider Name (Legal Business Name): LASER SPINE SURGICAL SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16604 107TH ST
ORLAND PARK IL
60467-8898
US

IV. Provider business mailing address

16604 107TH ST
ORLAND PARK IL
60467-8898
US

V. Phone/Fax

Practice location:
  • Phone: 708-966-8000
  • Fax: 708-460-0094
Mailing address:
  • Phone: 708-966-8000
  • Fax: 708-460-0094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: FARIS ABUSHARIF
Title or Position: OWNER-PHYSICIAN
Credential: MD
Phone: 708-460-9000