1912033390 NPI number — OMEED ZARDKOOHI MD

Table of content: OMEED ZARDKOOHI MD (NPI 1912033390)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912033390 NPI number — OMEED ZARDKOOHI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ZARDKOOHI
Provider First Name:
OMEED
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1912033390
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
351 DELNOR DR STE 302
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GENEVA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60134-4233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-202-0280
Provider Business Mailing Address Fax Number:
630-232-3895

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:
630-232-0280
Provider Business Practice Location Address Fax Number:
630-232-3895
Provider Enumeration Date:
02/27/2007

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: 207R00000X , with the licence number:  L-225514 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 036132874 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0001X , with the licence number: 036132874 , 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: 036132874 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 206147 . This is a "MEDICARE PTAN (GROUP)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 206147253 . This is a "MEDICARE PTAN (INDIVIDUAL)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CA4748 . This is a "MEDICARE RAILROAD (GROUP PTAN)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P01209469 . This is a "MEDICARE RAILROAD (PROVIDER PTAN)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".