Basic Information
| Provider Information | |||||||||
| NPI: | 1558416313 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAWZI | ||||||||
| FirstName: | AMANI | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 N LAKE SHORE DR | ||||||||
| Address2: | SUITE#1000 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606114546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126958150 | ||||||||
| FaxNumber: | 3126950050 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 N SAINT CLAIR ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126958150 | ||||||||
| FaxNumber: | 3126950050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 04/24/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 036129455 | IL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | A80549 | 01 | CA | LICENSE | OTHER | 036129455 | 05 | IL | MEDICAID | 036129455 | 01 | IL | LICENSE | OTHER |