Provider Demographics
NPI:1548697147
Name:INTERNATIONAL MEDICAL AND SURGICAL INSTITUTE,SC
Entity type:Organization
Organization Name:INTERNATIONAL MEDICAL AND SURGICAL INSTITUTE,SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-278-7024
Mailing Address - Street 1:3061 W LOGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-1707
Mailing Address - Country:US
Mailing Address - Phone:777-737-7278
Mailing Address - Fax:773-772-7896
Practice Address - Street 1:2359 N CALFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2939
Practice Address - Country:US
Practice Address - Phone:773-278-7024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36040647261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC41414Medicare UPIN