=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851429054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OBSTETRIC & GYNECOLOGIC ULTRASOUND.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2007
-----------------------------------------------------
Last Update Date | 10/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 680 N LAKE SHORE DR SUITE 1430
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-4546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-654-9100
-----------------------------------------------------
Fax | 312-654-9202
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 680 N LAKE SHORE DR SUITE 1430
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-4546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-735-2110
-----------------------------------------------------
Fax | 773-735-4238
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. RUDY E SABBAGHA
-----------------------------------------------------
Credential | MD,FACOG
-----------------------------------------------------
Telephone | 312-654-9100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085U0001X
-----------------------------------------------------
Taxonomy Name | Diagnostic Ultrasound Physician
-----------------------------------------------------
License Number | 036052551
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 036052551
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------