Provider Demographics
NPI:1093107989
Name:CHICAGO SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:CHICAGO SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:GARD
Authorized Official - Suffix:I
Authorized Official - Credentials:DC
Authorized Official - Phone:773-784-6682
Mailing Address - Street 1:1130 W GRANVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-2013
Mailing Address - Country:US
Mailing Address - Phone:773-784-6682
Mailing Address - Fax:773-784-5735
Practice Address - Street 1:1130 W GRANVILLE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-2013
Practice Address - Country:US
Practice Address - Phone:773-784-6682
Practice Address - Fax:773-784-5735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty