Provider Demographics
NPI:1649578105
Name:ILLINOIS SURGEON ASSOCIATION LLC
Entity Type:Organization
Organization Name:ILLINOIS SURGEON ASSOCIATION LLC
Other - Org Name:ISA DOH
Other - Org Type:Other Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MANDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FARAHATI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-787-2998
Mailing Address - Street 1:PO BOX 10523
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-0523
Mailing Address - Country:US
Mailing Address - Phone:312-787-2998
Mailing Address - Fax:312-787-7259
Practice Address - Street 1:60 E DELAWARE PL FL 15
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-1676
Practice Address - Country:US
Practice Address - Phone:312-787-2998
Practice Address - Fax:312-787-7259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004756133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty