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General NPI Number Information
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NPI Number | 1588656037
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Entity Type | Organization
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Legal Business Name | HYDE PARK MEDICAL SPECIALTY GROUP, LLC
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Dates
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Enumeration Date | 08/19/2005
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Last Update Date | 07/19/2012
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Provider Practice Location Address
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Address Line | 1644 E 53RD ST
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City | CHICAGO
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State | IL
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Zip | 60615-4210
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Country | US
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Telephone | 773-752-2111
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Fax | 773-752-6703
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Provider Business Mailing Address
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Address Line | 9933 S WESTERN AVE SUITE 102
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City | CHICAGO
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State | IL
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Zip | 60643-1810
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Country | US
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Telephone | 773-233-3800
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Fax | 773-233-2513
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Authorized Official
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Title or Position | MEDICAL DIRECTOR/CEO
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Name | MRS. FORTUNEE MASSUDA
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Credential | DPM
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Telephone | 773-752-2111
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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 | IL
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Taxonomy #2
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State |
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