Provider Demographics
NPI:1194901280
Name:MARIO C. ROSAS, M.D., S.C.
Entity type:Organization
Organization Name:MARIO C. ROSAS, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROSAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-522-2620
Mailing Address - Street 1:2619 S LAWNDALE AVE
Mailing Address - Street 2:FRONT
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-4520
Mailing Address - Country:US
Mailing Address - Phone:773-522-2620
Mailing Address - Fax:773-522-2641
Practice Address - Street 1:2619 S LAWNDALE AVE
Practice Address - Street 2:FRONT
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-4520
Practice Address - Country:US
Practice Address - Phone:773-522-2620
Practice Address - Fax:773-522-2641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036074065207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty