1790893881 NPI number — FARAH HASHEMI FAKOURI

Table of content: FARAH HASHEMI FAKOURI (NPI 1790893881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790893881 NPI number — FARAH HASHEMI FAKOURI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HASHEMI FAKOURI
Provider First Name:
FARAH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HASHEMI
Provider Other First Name:
FARAH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1790893881
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 N WINFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60190-1295
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-933-1199
Provider Business Mailing Address Fax Number:
630-933-4558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 N WINFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60190-1295
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-933-1199
Provider Business Practice Location Address Fax Number:
630-933-4558
Provider Enumeration Date:
08/28/2006

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: 207RI0200X , with the licence number:  101311 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X , with the licence number: 036089264 , 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: 036089264 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: K53368 . This is a "MEDICARE PTAN (INDIVIDUAL)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00708155 . This is a "RR MEDICARE PTAN (INDIVIDUAL)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 206147 . This is a "MEDICARE PTAN (GROUP)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".