=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396142857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLINOIS INSTITUTE OF GYNECOLOGY AND ADVANCED PELVIC SURGERY, SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2014
-----------------------------------------------------
Last Update Date | 01/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1351 W BELMONT AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-7195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-785-8881
-----------------------------------------------------
Fax | 312-956-2733
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1351 W BELMONT AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-7195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-785-8881
-----------------------------------------------------
Fax | 312-956-2733
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ALLAN ADAM ADAJAR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 773-428-0624
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | 036124772
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------