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General NPI Number Information
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NPI Number | 1447559000
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Entity Type | Organization
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Legal Business Name | LOGAN SQUARE MEDICAL INSTITUTE SC
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Dates
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Enumeration Date | 03/22/2011
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Last Update Date | 02/09/2015
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Provider Practice Location Address
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Address Line | 3061 W. LOGAN BLVD
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City | CHICAGO
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State | IL
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Zip | 60647-1707
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Country | US
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Telephone | 773-772-7899
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Fax | 773-772-7896
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Provider Business Mailing Address
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Address Line | 3061 W. LOGAN BLVD
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City | CHICAGO
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State | IL
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Zip | 60647
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Country | US
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Telephone | 773-772-7899
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Fax | 773-772-7896
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. GONZALO RUIZ
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Credential | M.D.
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Telephone | 773-772-7899
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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