=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144482290
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAND AVENUE SURGICAL CENTER, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2008
-----------------------------------------------------
Last Update Date | 08/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 W GRAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-4306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-222-5610
-----------------------------------------------------
Fax | 312-661-1771
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 W GRAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-4306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-222-5610
-----------------------------------------------------
Fax | 312-661-1771
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR & COO
-----------------------------------------------------
Name | MR. JAVAD NERCY JAFARI
-----------------------------------------------------
Credential | M.B.A.
-----------------------------------------------------
Telephone | 312-222-5610
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 7003133
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------