Provider Demographics
NPI:1588656037
Name:HYDE PARK MEDICAL SPECIALTY GROUP, LLC
Entity Type:Organization
Organization Name:HYDE PARK MEDICAL SPECIALTY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:FORTUNEE
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSUDA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-752-2111
Mailing Address - Street 1:9933 S WESTERN AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1810
Mailing Address - Country:US
Mailing Address - Phone:773-233-3800
Mailing Address - Fax:773-233-2513
Practice Address - Street 1:1644 E 53RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4210
Practice Address - Country:US
Practice Address - Phone:773-752-2111
Practice Address - Fax:773-752-6703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207L00000X
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01633434OtherBCBS
IL208013Medicare ID - Type UnspecifiedMEDICARE
IL01633434OtherBCBS