Provider Demographics
NPI:1811035462
Name:VASECTOMY CLINICS OF CHICAGO
Entity Type:Organization
Organization Name:VASECTOMY CLINICS OF CHICAGO
Other - Org Name:KIUMARS MOSTOWFI, M.D., S.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIUMARS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSTOWFI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-528-9068
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-0669
Mailing Address - Country:US
Mailing Address - Phone:312-528-9068
Mailing Address - Fax:312-278-4492
Practice Address - Street 1:505 N LAKE SHORE DR
Practice Address - Street 2:SUITE 203
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3427
Practice Address - Country:US
Practice Address - Phone:312-528-9068
Practice Address - Fax:312-278-4492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036046251208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC42066Medicare UPIN