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General NPI Number Information
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NPI Number | 1518607696
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Entity Type | Organization
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Legal Business Name | 2001-15 N PARKSIDE LLC
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Dates
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Enumeration Date | 03/29/2022
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Last Update Date | 03/29/2022
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Provider Practice Location Address
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Address Line | 405 N WABASH AVE STE P2-A
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City | CHICAGO
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State | IL
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Zip | 60611-3744
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Country | US
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Telephone | 312-955-4005
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Fax |
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Provider Business Mailing Address
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Address Line | 18140 AUDETTE ST
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City | DEARBORN
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State | MI
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Zip | 48124-4217
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Country | US
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Telephone | 312-998-5229
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. MONA KHAN
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Credential | DO
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Telephone | 312-955-4005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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