Healthcare Provider Details

I. General information

NPI: 1124556444
Provider Name (Legal Business Name): ELGIN SURGICARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 W CHICAGO AVE
EAST CHICAGO IN
46312-3206
US

IV. Provider business mailing address

4941 N KEDZIE AVE
CHICAGO IL
60625-5009
US

V. Phone/Fax

Practice location:
  • Phone: 630-345-0834
  • Fax:
Mailing address:
  • Phone: 773-509-9099
  • Fax: 773-509-9006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1952663593
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01077720A
License Number StateIN

VIII. Authorized Official

Name: TANIA KHAMOO
Title or Position: ADMINISTRATOR
Credential:
Phone: 773-309-6740