Provider Demographics
NPI:1447426879
Name:FAMILY MEDICINE OF ILLINOIS SC
Entity Type:Organization
Organization Name:FAMILY MEDICINE OF ILLINOIS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SYEDA
Authorized Official - Middle Name:AISHA
Authorized Official - Last Name:IFTIKHAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:224-567-8371
Mailing Address - Street 1:1507 S FALCON DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-4897
Mailing Address - Country:US
Mailing Address - Phone:847-494-0265
Mailing Address - Fax:
Practice Address - Street 1:1507 S FALCON DR
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-4897
Practice Address - Country:US
Practice Address - Phone:847-494-0265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102332207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102332Medicaid
207R00000XOtherTAXONOMY SPECIALITY CODE
NE1770599938OtherNPI INDIVIDUAL NUMBER
207R00000XOtherTAXONOMY SPECIALITY CODE