Provider Demographics
NPI:1518607696
Name:2001-15 N PARKSIDE LLC
Entity Type:Organization
Organization Name:2001-15 N PARKSIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:312-955-4005
Mailing Address - Street 1:18140 AUDETTE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4217
Mailing Address - Country:US
Mailing Address - Phone:312-998-5229
Mailing Address - Fax:
Practice Address - Street 1:405 N WABASH AVE STE P2-A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3744
Practice Address - Country:US
Practice Address - Phone:312-955-4005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center