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General NPI Number Information
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NPI Number | 1104094804
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Entity Type | Organization
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Legal Business Name | SOUTHWEST HEAD & NECK SURGICAL ASSOC SC
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Dates
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Enumeration Date | 02/15/2008
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Last Update Date | 05/14/2012
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Provider Practice Location Address
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Address Line | 1000 RAVINIA PL
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City | ORLAND PARK
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State | IL
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Zip | 60462-3764
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Country | US
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Telephone | 708-460-6663
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Fax | 708-460-6693
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Provider Business Mailing Address
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Address Line | 1000 RAVINIA PL
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City | ORLAND PARK
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State | IL
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Zip | 60462-3764
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Country | US
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Telephone | 708-460-6663
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Fax | 708-460-6693
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOSEPH P GAVRON
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Credential | MD
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Telephone | 708-460-6663
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 036054754
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License Number State | IL
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