MEDICARE: GRAND AVENUE SURGICAL CENTER, LTD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	7003133	IL

General Provider Information

NPI Number	:	1144482290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND AVENUE SURGICAL CENTER, LTD.

Provider Business Mailing Address
First Line	:	17 W GRAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-4306
Country	:	US
Telephone Number	:	312-222-5610
Fax Number	:	312-661-1771

Provider Business Practice Location Address
First Line	:	17 W GRAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-4306
Country	:	US
Telephone Number	:	312-222-5610
Fax Number	:	312-661-1771

Authorized Official
Title or Position	:	ADMINISTRATOR & COO
Name	:	MR. JAVAD NERCY JAFARI
Credential	:	M.B.A.
Telephone Number	:	312-222-5610

Provider Enumeration Date	:	06/30/2008
Last Update Date	:	08/05/2019

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