Provider Demographics
NPI:1275550014
Name:FARHAD VOSSOUGHI MD SC
Entity Type:Organization
Organization Name:FARHAD VOSSOUGHI MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:FARHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:VOSSOUGHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-321-2710
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0967
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3825 HIGHLAND AVE
Practice Address - Street 2:SUITE 2B
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1552
Practice Address - Country:US
Practice Address - Phone:630-646-2987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053514208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0002201788OtherBCBS OF IL
ILDE0652Medicare PIN
IL211912Medicare PIN
IL211911Medicare PIN