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General NPI Number Information
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NPI Number | 1154550226
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Entity Type | Organization
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Legal Business Name | PROGRESSIVE SURGICAL ASSOCIATES SC
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Dates
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Enumeration Date | 07/09/2009
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Last Update Date | 08/09/2012
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Provider Practice Location Address
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Address Line | 1890 SILVER CROSS BLVD SUITE 410
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City | NEW LENOX
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State | IL
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Zip | 60451-9524
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Country | US
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Telephone | 815-717-8730
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Fax | 815-717-8729
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Provider Business Mailing Address
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Address Line | 1890 SILVER CROSS BLVD SUITE 410
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City | NEW LENOX
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State | IL
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Zip | 60451-9524
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Country | US
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Telephone | 815-717-8730
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Fax | 815-717-8729
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Authorized Official
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Title or Position | OWNER
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Name | REZA GAMAGAMI
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Credential | MD
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Telephone | 815-717-8730
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 036103521
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License Number State | IL
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