Healthcare Provider Details

I. General information

NPI: 1801303714
Provider Name (Legal Business Name): LASER SPINE CENTER OF CHICAGO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 04/26/2018
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: 847-854-5192
  • Fax:
Mailing address:
  • Phone: 708-966-8000
  • Fax: 708-966-2836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: FARIS ABUSHARIF
Title or Position: OWNER-PHYSICIAN
Credential: MD
Phone: 847-854-5192