Basic Information
| Provider Information | |||||||||
| NPI: | 1194726851 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOZORGZADEH | ||||||||
| FirstName: | SHAHRIAR | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1467 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462061467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184575200 | ||||||||
| FaxNumber: | 6185290586 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 W JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185490721 | ||||||||
| FaxNumber: | 6184570469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036-096984 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 36096984 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3932056 | 01 | IL | BLUE SHIELD | OTHER | 0360096984 | 05 | IL | MEDICAID | 036096984 | 05 | IL | MEDICAID |