=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619354081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR ELBORNO CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2015
-----------------------------------------------------
Last Update Date | 09/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6747 KINGERY HWY
-----------------------------------------------------
City | WILLOWBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60527-5142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-952-1412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6747 KINGERY HWY
-----------------------------------------------------
City | WILLOWBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60527-5142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-952-1412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. AHMED ELBORNO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 630-952-1412
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------