=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518282805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHY FAMILY MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2010
-----------------------------------------------------
Last Update Date | 03/30/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2636 W 71ST ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60629-2082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-776-9822
-----------------------------------------------------
Fax | 773-776-9865
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2636 W 71ST ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60629-2082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-776-9822
-----------------------------------------------------
Fax | 773-776-9865
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MASOOD S SYED
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 773-776-9822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 036-084772
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------