Basic Information
| Provider Information | |||||||||
| NPI: | 1750635868 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHICAGO CENTER FOR ANTI AGING INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 N NORTHWEST HWY STE 102 | ||||||||
| Address2: | |||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600682349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309521412 | ||||||||
| FaxNumber: | 6309521447 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 N NORTHWEST HWY STE 102 | ||||||||
| Address2: | |||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600682349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309521412 | ||||||||
| FaxNumber: | 6309521447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2012 | ||||||||
| LastUpdateDate: | 10/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | SPERON | ||||||||
| AuthorizedOfficialFirstName: | SAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6309521412 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.