Basic Information
| Provider Information | |||||||||
| NPI: | 1205368289 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUSAIN | ||||||||
| FirstName: | AFSHAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4025 N SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606132010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192514554 | ||||||||
| FaxNumber: | 4192516795 | ||||||||
| Practice Location | |||||||||
| Address1: | 4025 N SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606132010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192514554 | ||||||||
| FaxNumber: | 4192516795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2017 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 036.157749 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036.157749 | 05 | IL | MEDICAID |