1154505279 NPI number — TARANEH S FIROOZI MD SC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154505279 NPI number — TARANEH S FIROOZI MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TARANEH S FIROOZI MD SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1154505279
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5600 W ADDISON ST
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-736-6999
Provider Business Mailing Address Fax Number:
773-736-2643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5600 W ADDISON ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-736-6999
Provider Business Practice Location Address Fax Number:
773-736-2643
Provider Enumeration Date:
12/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FIROOZI
Authorized Official First Name:
TARANEH
Authorized Official Middle Name:
SAHIHI
Authorized Official Title or Position:
OWNER DERMATOLOGIST
Authorized Official Telephone Number:
773-736-6999

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  36045349 , 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: 036045349 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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