=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295914497
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EQUINOX HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2007
-----------------------------------------------------
Last Update Date | 10/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5122 W IRVING PARK RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60641-2624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-282-7952
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5122 W IRVING PARK RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60641-2624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | GREG BIGAJ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-282-7952
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 36108386
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------