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NPI Code Detail

MEDICARE: HYDE PARK SURGERY CENTER, LLC

MEDICARE: HYDE PARK SURGERY CENTER, LLC
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
1261QA1903XAmbulatory Surgical Clinic/Center

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
150460OTHERILBCBS

General Provider Information

NPI Number : 1609868041
Entity Type Code : Organization
Provider Name (Legal Business Name) : HYDE PARK SURGERY CENTER, LLC
Provider Business Mailing Address
First Line : 9933 S WESTERN AVE
Second Line : SUITE 102
City : CHICAGO
State : IL
Zip : 60643-1810
Country : US
Telephone Number : 773-233-3800
Fax Number : 773-233-2513
Provider Business Practice Location Address
First Line : 1644 E 53RD ST
Second Line :
City : CHICAGO
State : IL
Zip : 60615-4210
Country : US
Telephone Number : 773-752-2111
Fax Number : 773-752-6703
Authorized Official
Title or Position : MEDICAL DIRECTOR & CEO
Name : MRS. FORTUNEE MASSUDA
Credential : DPM
Telephone Number : 773-752-2111
Provider Enumeration Date : 08/22/2005
Last Update Date : 11/23/2009

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Directions to “HYDE PARK SURGERY CENTER, LLC ” Practice Location

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