Provider Demographics
NPI:1629015524
Name:AFFILIATED CHICAGO PHYSICIANS
Entity Type:Organization
Organization Name:AFFILIATED CHICAGO PHYSICIANS
Other - Org Name:AFFILIATED CHICAGO PHYSICIANS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
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:773-395-9400
Mailing Address - Street 1:4849 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-2503
Mailing Address - Country:US
Mailing Address - Phone:773-237-0755
Mailing Address - Fax:773-237-0785
Practice Address - Street 1:4849 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-2503
Practice Address - Country:US
Practice Address - Phone:773-237-0755
Practice Address - Fax:773-237-0785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Not Answered213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID
IL=========OtherTAX ID