Basic Information
| Provider Information | |||||||||
| NPI: | 1558600957 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHICAGO INSTITUTE OF ADVANCED SURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 N HALSTED ST STE 703 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733276800 | ||||||||
| FaxNumber: | 7733276877 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 N HALSTED ST STE 703 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733276800 | ||||||||
| FaxNumber: | 7733276877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2013 | ||||||||
| LastUpdateDate: | 10/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | LUTFI | ||||||||
| AuthorizedOfficialFirstName: | RAMI | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7733276800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 10/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 36124476 | 05 | IL | MEDICAID | F400193534 | 01 | MC | OTHER |