=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497401970
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED SURGERY & WELLNESS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2022
-----------------------------------------------------
Last Update Date | 05/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 163 S RANDALL RD
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60123-5551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-406-1007
-----------------------------------------------------
Fax | 847-695-2377
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 163 S RANDALL RD
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60123-5551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-406-1007
-----------------------------------------------------
Fax | 847-695-2377
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | ADAM DUNN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-406-1007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------