1861408510 NPI number — SHERVIN DORODI MD

Table of content: SHERVIN DORODI MD (NPI 1861408510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861408510 NPI number — SHERVIN DORODI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DORODI
Provider First Name:
SHERVIN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861408510
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 E GOLF ROAD
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
DES PLAINES
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60016-1252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-297-2636
Provider Business Mailing Address Fax Number:
847-297-3252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 E GOLF ROAD
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
DES PLAINES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60016-1252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-297-2636
Provider Business Practice Location Address Fax Number:
847-297-3252
Provider Enumeration Date:
08/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A85638 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 54267 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 036105942 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 775321 . This is a "GOLD PLUS HUMANA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 01634205 . This is a "BCBS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 8701968 . This is a "CIGNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036105942 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".