Basic Information
| Provider Information | |||||||||
| NPI: | 1760504716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCURRY | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | LYNETTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MASON | ||||||||
| OtherFirstName: | KAREN | ||||||||
| OtherMiddleName: | LYNETTE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3860 WEST OGDEN AVENUE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738433000 | ||||||||
| FaxNumber: | 7738432704 | ||||||||
| Practice Location | |||||||||
| Address1: | 3860 WEST OGDEN AVENUE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738433000 | ||||||||
| FaxNumber: | 7738432704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085000939 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 085000939 | 01 | IL | STATE LICENSE | OTHER | 385000282 | 01 | IL | CS LICENSE | OTHER | 1034924 | 01 | IL | SPECIALTY BOARDS | OTHER | MM0873566 | 01 | IL | DEA | OTHER |