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General NPI Number Information
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NPI Number | 1154412120
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Entity Type | Organization
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Legal Business Name | SURGICORE, INC.
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Dates
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Enumeration Date | 09/27/2006
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Last Update Date | 08/11/2011
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Provider Practice Location Address
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Address Line | 10547 S EWING AVE
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City | CHICAGO
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State | IL
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Zip | 60617-6220
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Country | US
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Telephone | 773-221-1690
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Fax | 773-221-1675
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Provider Business Mailing Address
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Address Line | 10547 S EWING AVE
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City | CHICAGO
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State | IL
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Zip | 60617-6220
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Country | US
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Telephone | 773-221-1690
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Fax | 773-221-1675
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | MICHAEL ANDREW WOOD
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Credential | D.P.M.
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Telephone | 773-221-1690
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 7003072
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License Number State | IL
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