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General NPI Number Information
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NPI Number | 1194901280
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Entity Type | Organization
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Legal Business Name | MARIO C. ROSAS, M.D., S.C.
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Dates
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Enumeration Date | 01/18/2008
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Last Update Date | 06/14/2016
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Provider Practice Location Address
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Address Line | 2619 S LAWNDALE AVE FRONT
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City | CHICAGO
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State | IL
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Zip | 60623-4520
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Country | US
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Telephone | 773-522-2620
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Fax | 773-522-2641
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Provider Business Mailing Address
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Address Line | 2619 S LAWNDALE AVE FRONT
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City | CHICAGO
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State | IL
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Zip | 60623-4520
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Country | US
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Telephone | 773-522-2620
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Fax | 773-522-2641
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARIO C ROSAS
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Credential | M.D.
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Telephone | 773-522-2620
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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 | 036074065
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License Number State | IL
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