Provider Demographics
NPI:1619134301
Name:WESTSIDE ANESTHESIA CONSULTANTS, S.C.
Entity Type:Organization
Organization Name:WESTSIDE ANESTHESIA CONSULTANTS, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:WYGODNY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-593-4607
Mailing Address - Street 1:2128 W CORTEZ ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3601
Mailing Address - Country:US
Mailing Address - Phone:773-593-4607
Mailing Address - Fax:
Practice Address - Street 1:2128 W CORTEZ ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3601
Practice Address - Country:US
Practice Address - Phone:773-593-4607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042616725207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG64711Medicare UPIN