Provider Demographics
NPI:1528366234
Name:PROFESSIONAL PSYCHIATRY INC.
Entity Type:Organization
Organization Name:PROFESSIONAL PSYCHIATRY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GHAZALA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAYYAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-312-3506
Mailing Address - Street 1:9446 LATROBE AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1112
Mailing Address - Country:US
Mailing Address - Phone:847-312-4219
Mailing Address - Fax:
Practice Address - Street 1:4433 W TOUHY AVE STE 262
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-1833
Practice Address - Country:US
Practice Address - Phone:847-312-3376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-03
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1136342084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113634Medicaid
IL036113634Medicaid