Provider Demographics
NPI:1932429784
Name:CHICAGO WEIGHT LOSS CLINIC, LLC
Entity Type:Organization
Organization Name:CHICAGO WEIGHT LOSS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DHARAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-565-1010
Mailing Address - Street 1:155 N HARBOR DR
Mailing Address - Street 2:# 5212
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7364
Mailing Address - Country:US
Mailing Address - Phone:312-565-1010
Mailing Address - Fax:312-565-1212
Practice Address - Street 1:1 E SUPERIOR ST
Practice Address - Street 2:# 306
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2507
Practice Address - Country:US
Practice Address - Phone:312-565-1010
Practice Address - Fax:312-565-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-03
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036044803207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty