Provider Demographics
NPI:1063445476
Name:FOROUTAN & ASSOCIATES SC
Entity Type:Organization
Organization Name:FOROUTAN & ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARDJAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOROUTAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-222-5574
Mailing Address - Street 1:920 W PRAIRIE DR STE I
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3123
Mailing Address - Country:US
Mailing Address - Phone:708-532-6029
Mailing Address - Fax:708-532-6095
Practice Address - Street 1:2111 MIDLANDS CT
Practice Address - Street 2:SUITE 202
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3125
Practice Address - Country:US
Practice Address - Phone:630-222-5574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361103602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001932083OtherBCBS PROVIDER #
ILDF7197Medicare PIN
IL0001932083OtherBCBS PROVIDER #
IL216890Medicare PIN