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General NPI Number Information
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NPI Number | 1700903309
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Entity Type | Organization
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Legal Business Name | KM SURGICAL, P.C.
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 08/15/2019
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Provider Practice Location Address
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Address Line | 505 N LAKE SHORE DR SUITE 203
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City | CHICAGO
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State | IL
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Zip | 60611
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Country | US
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Telephone | 312-528-9068
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Fax | 312-278-4492
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Provider Business Mailing Address
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Address Line | PO BOX 669
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City | LIBERTYVILLE
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State | IL
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Zip | 60048-0669
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Country | US
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Telephone | 312-528-9068
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Fax | 312-278-4492
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KIUMARS MOSTOWFI
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Credential | M.D.
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Telephone | 312-528-9068
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 036046251
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License Number State | IL
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