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General NPI Number Information
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NPI Number | 1376701805
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Entity Type | Organization
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Legal Business Name | STARSURGICAL
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Dates
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Enumeration Date | 05/30/2008
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Last Update Date | 04/28/2011
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Provider Practice Location Address
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Address Line | 2373 WHITE ROSE DR
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City | MONTGOMERY
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State | IL
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Zip | 60538-5140
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Country | US
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Telephone | 630-330-1761
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Fax | 630-762-9681
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Provider Business Mailing Address
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Address Line | PO BOX 88543
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City | CAROL STREAM
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State | IL
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Zip | 60188-0543
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Country | US
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Telephone | 630-330-1761
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Fax | 630-762-9681
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Authorized Official
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Title or Position | PHYSICIAN
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Name | JOSE ESPINO
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Credential | RCSA
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Telephone | 630-330-1761
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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 | 238.000022
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License Number State | IL
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