Basic Information
| Provider Information | |||||||||
| NPI: | 1588817605 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NABAVI | ||||||||
| FirstName: | SEYED MAHMOUD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NABAVI | ||||||||
| OtherFirstName: | SEYED MAHMOUD | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4901 W 79TH ST | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604591554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084991545 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4901 W 79TH ST | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604591554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084991545 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2008 | ||||||||
| LastUpdateDate: | 02/10/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 085004504 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.