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General NPI Number Information
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NPI Number | 1114321353
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Entity Type | Organization
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Legal Business Name | AURORA HEALTHCARE INC
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Dates
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Enumeration Date | 10/17/2014
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Last Update Date | 10/17/2014
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Provider Practice Location Address
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Address Line | 1502 W CHICAGO AVE
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City | CHICAGO
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State | IL
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Zip | 60642-5236
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Country | US
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Telephone | 773-672-2561
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Fax | 773-672-2560
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Provider Business Mailing Address
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Address Line | 1502 W CHICAGO AVE
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City | CHICAGO
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State | IL
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Zip | 60642-5236
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Country | US
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Telephone | 773-672-2561
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Fax | 773-672-2560
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Authorized Official
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Title or Position | OWNER
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Name | GENNADII KARANDIEIEV
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Credential |
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Telephone | 773-672-2561
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036.059705
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License Number State | IL
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