Basic Information
| Provider Information | |||||||||
| NPI: | 1689802340 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHOSROPOUR | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | MINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4848 W IRVING PARK RD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606412718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737246200 | ||||||||
| FaxNumber: | 7735643510 | ||||||||
| Practice Location | |||||||||
| Address1: | 213 N RACINE AVE | ||||||||
| Address2: | 100 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606071644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127739730 | ||||||||
| FaxNumber: | 7738668014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2009 | ||||||||
| LastUpdateDate: | 05/21/2015 | ||||||||
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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 | 207Q00000X | 125057197 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.