=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093850331
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAPAROSCOPY INTERNATIONAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2007
-----------------------------------------------------
Last Update Date | 12/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3714 W 26TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60623-3824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-810-0212
-----------------------------------------------------
Fax | 630-810-1027
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4333 MAIN ST
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515-2869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-810-0212
-----------------------------------------------------
Fax | 630-810-1027
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MRS. KRISTINA L BUTLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-810-1219
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 036050637
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 036050637
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------