Provider Demographics
NPI:1831104652
Name:NORTHWEST ADVANCED SURGICAL ASSOCIATES, SC
Entity type:Organization
Organization Name:NORTHWEST ADVANCED SURGICAL ASSOCIATES, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SPIROS
Authorized Official - Middle Name:
Authorized Official - Last Name:GIANNOULIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-478-5600
Mailing Address - Street 1:6374 N LINCOLN AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-1275
Mailing Address - Country:US
Mailing Address - Phone:773-478-5600
Mailing Address - Fax:773-478-5602
Practice Address - Street 1:6374 N LINCOLN AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-1275
Practice Address - Country:US
Practice Address - Phone:773-478-5600
Practice Address - Fax:773-478-5602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01620367OtherBCBS
ILCC3272OtherRAILROAD MEDICARE
IL14D0907680OtherCLIA
IL382480Medicare PIN