Provider Demographics
NPI:1114063989
Name:GAJDA SPORTS MEDICAL CENTER LTD
Entity Type:Organization
Organization Name:GAJDA SPORTS MEDICAL CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:GAJDA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-352-2392
Mailing Address - Street 1:521 MALDEN AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-5514
Mailing Address - Country:US
Mailing Address - Phone:708-352-2392
Mailing Address - Fax:708-352-2738
Practice Address - Street 1:400 LAKE COOK ROAD SUITE 200C
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015
Practice Address - Country:US
Practice Address - Phone:708-352-2392
Practice Address - Fax:708-352-2738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066049204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
715700Medicare ID - Type Unspecified