Basic Information
Provider Information | |||||||||
NPI: | 1063445476 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FOROUTAN & ASSOCIATES SC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 920 W PRAIRIE DR STE I | ||||||||
Address2: |   | ||||||||
City: | SYCAMORE | ||||||||
State: | IL | ||||||||
PostalCode: | 601783123 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7085326029 | ||||||||
FaxNumber: | 7085326095 | ||||||||
Practice Location | |||||||||
Address1: | 2111 MIDLANDS CT | ||||||||
Address2: | SUITE 202 | ||||||||
City: | SYCAMORE | ||||||||
State: | IL | ||||||||
PostalCode: | 601783125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6302225574 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2006 | ||||||||
LastUpdateDate: | 05/21/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FOROUTAN | ||||||||
AuthorizedOfficialFirstName: | MARDJAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6302225574 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 036110360 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 0001932083 | 01 | IL | BCBS PROVIDER # | OTHER |