Healthcare Provider Details

I. General information

NPI: 1548533870
Provider Name (Legal Business Name): SKOKIE MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2012
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8301 SKOKIE BLVD
SKOKIE IL
60077-2546
US

IV. Provider business mailing address

3S138 PARK BLVD
GLEN ELLYN IL
60137-7233
US

V. Phone/Fax

Practice location:
  • Phone: 847-674-4481
  • Fax: 847-674-4491
Mailing address:
  • Phone: 630-605-2646
  • Fax: 630-790-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number036106820
License Number StateIL

VIII. Authorized Official

Name: MR. MEHDI BASSIRATPOUR
Title or Position: OWNER/MANAGER
Credential: M.D.
Phone: 630-605-2646