=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598907792
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AFFILIATED SURGICARE,LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2009
-----------------------------------------------------
Last Update Date | 04/02/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4200 W 63RD ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60629-5010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-237-0855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4200 W 63RD ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60629-5010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-237-0855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. NASER RUSTOM
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 773-237-0755
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------