=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649612961
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN CRAIG FOX D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2013
-----------------------------------------------------
Last Update Date | 07/29/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 NORTH HALSTED STREET SUITE 303
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60661-2156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-258-0575
-----------------------------------------------------
Fax | 312-648-1569
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 NORTH HALSTED STREET SUITE 303
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60661-2156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-258-0575
-----------------------------------------------------
Fax | 312-648-1569
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 036.064714
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------