Basic Information
| Provider Information | |||||||||
| NPI: | 1306987896 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASSOCIATED UROLOGICAL SPECIALISTS LLC | ||||||||
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| OtherOrganizationName: | MIDWEST UROLOGY-EVERGREEN PARK | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10400 SOUTHEST HIGHWAY | ||||||||
| Address2: | LOWER LEVEL | ||||||||
| City: | CHICAGO RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085817308 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2850 W 95TH ST | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608052735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084222242 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROQUE | ||||||||
| AuthorizedOfficialFirstName: | ELIZA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7086082195 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.