Provider Demographics
NPI:1609120138
Name:PHYSICIAN URGENT CARE OF ILLINOIS, INC.
Entity Type:Organization
Organization Name:PHYSICIAN URGENT CARE OF ILLINOIS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NASER
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSTOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-237-3500
Mailing Address - Street 1:4941 N KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5009
Mailing Address - Country:US
Mailing Address - Phone:773-309-6714
Mailing Address - Fax:773-309-6298
Practice Address - Street 1:1554 TODD FARM DR
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-1287
Practice Address - Country:US
Practice Address - Phone:847-888-7423
Practice Address - Fax:847-841-7285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care