=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265755177
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVANT-GARDE MEDICNE SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2010
-----------------------------------------------------
Last Update Date | 07/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 S CALIFORNIA BLVD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-522-2010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 W WASHINGTON ST # 5006
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60606-3543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-767-0137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DEEPTHI S SAXENA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 847-767-0137
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------