Basic Information
| Provider Information | |||||||||
| NPI: | 1285675678 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FULLERTON SURGERY CENTER LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FULLERTON SURGERY CENTER INC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4849 W FULLERTON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606392503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732372900 | ||||||||
| FaxNumber: | 7736220769 | ||||||||
| Practice Location | |||||||||
| Address1: | 4849 W FULLERTON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606392503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732372900 | ||||||||
| FaxNumber: | 7736220769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 02/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | RUSTOM | ||||||||
| AuthorizedOfficialFirstName: | NASER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7732372900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 042618689 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.