Provider Demographics
NPI:1497242770
Name:EHSAN, BAZAL
Entity Type:Individual
Prefix:
First Name:BAZAL
Middle Name:
Last Name:EHSAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 RIDGE LN APT 4
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-3049
Mailing Address - Country:US
Mailing Address - Phone:224-436-6848
Mailing Address - Fax:
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-3049
Practice Address - Country:US
Practice Address - Phone:309-339-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-22
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036156383208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program