Provider Demographics
NPI:1598462426
Name:ADVANCED GYNECOLOGY PRACTICE LLC
Entity Type:Organization
Organization Name:ADVANCED GYNECOLOGY PRACTICE LLC
Other - Org Name:ADVANCED ENDOMETRIOSIS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FADEL
Authorized Official - Middle Name:FONS TALASOUN
Authorized Official - Last Name:AZER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:331-702-2455
Mailing Address - Street 1:3033 OGDEN AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1976
Mailing Address - Country:US
Mailing Address - Phone:331-702-2455
Mailing Address - Fax:331-229-8191
Practice Address - Street 1:3033 OGDEN AVE STE 300
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1976
Practice Address - Country:US
Practice Address - Phone:331-702-2455
Practice Address - Fax:331-229-8191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty