Basic Information
Provider Information | |||||||||
NPI: | 1336393875 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANJABI | ||||||||
FirstName: | PARVIZ | ||||||||
MiddleName: | B. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P O BOX 577 | ||||||||
Address2: |   | ||||||||
City: | CARTERVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 629180577 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6189858221 | ||||||||
FaxNumber: | 6189856860 | ||||||||
Practice Location | |||||||||
Address1: | 1335 CEDAR COURT | ||||||||
Address2: |   | ||||||||
City: | CARBONDALE | ||||||||
State: | IL | ||||||||
PostalCode: | 62901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6184578520 | ||||||||
FaxNumber: | 6184578560 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/11/2008 | ||||||||
LastUpdateDate: | 04/19/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 036051114 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 036051114 | 05 | IL |   | MEDICAID | CF3444 | 01 | IL | MEDICARE RR GROUP | OTHER | 133133805 | 01 | IL | DOL BLACK LUNG | OTHER | 370966854018 | 05 | IL |   | MEDICAID | 640701001 | 01 | IL | MEDICARE PTAN | OTHER |