MEDICARE: INTERNATIONAL MEDICAL AND SURGICAL INSTITUTE,SC

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	36040647	IL

General Provider Information

NPI Number	:	1548697147
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERNATIONAL MEDICAL AND SURGICAL INSTITUTE,SC

Provider Business Mailing Address
First Line	:	3061 W LOGAN BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-1707
Country	:	US
Telephone Number	:	777-737-7278
Fax Number	:	773-772-7896

Provider Business Practice Location Address
First Line	:	2359 N CALFORNIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2939
Country	:	US
Telephone Number	:	773-278-7024
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GONZALO RUIZ
Credential	:	M.D.
Telephone Number	:	773-278-7024

Provider Enumeration Date	:	09/27/2013
Last Update Date	:	09/27/2013

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