Provider Demographics
NPI:1144482290
Name:GRAND AVENUE SURGICAL CENTER, LTD.
Entity type:Organization
Organization Name:GRAND AVENUE SURGICAL CENTER, LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR & COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAVAD
Authorized Official - Middle Name:NERCY
Authorized Official - Last Name:JAFARI
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:312-222-5610
Mailing Address - Street 1:17 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-4306
Mailing Address - Country:US
Mailing Address - Phone:312-222-5610
Mailing Address - Fax:312-661-1771
Practice Address - Street 1:17 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-4306
Practice Address - Country:US
Practice Address - Phone:312-222-5610
Practice Address - Fax:312-661-1771
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:J N R ASSOCIATES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-30
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7003133261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical