Provider Demographics
NPI:1275918112
Name:AVANT -GARDE MEDICNE SC
Entity Type:Organization
Organization Name:AVANT -GARDE MEDICNE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEEPTHI
Authorized Official - Middle Name:S
Authorized Official - Last Name:SAXENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-566-4343
Mailing Address - Street 1:1401 S CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1858
Mailing Address - Country:US
Mailing Address - Phone:773-522-2010
Mailing Address - Fax:
Practice Address - Street 1:215 W WASHINGTON ST APT 5006
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-3543
Practice Address - Country:US
Practice Address - Phone:702-566-5343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-111103208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty