Basic Information
| Provider Information | |||||||||
| NPI: | 1265767537 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ABDOL HOSSEINIAN MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4250 N MARINE DR | ||||||||
| Address2: | SUITE 236 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606131744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734040160 | ||||||||
| FaxNumber: | 7734049876 | ||||||||
| Practice Location | |||||||||
| Address1: | 4250 N MARINE DR | ||||||||
| Address2: | SUITE 236 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606131744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734040160 | ||||||||
| FaxNumber: | 7734049876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2009 | ||||||||
| LastUpdateDate: | 10/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | HOSSEINIAN | ||||||||
| AuthorizedOfficialFirstName: | ABDOL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7734040160 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 0360440385 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 036044385 | 05 | IL | MEDICAID |