Provider Demographics
NPI:1578639498
Name:A REZVAN MD SC AND ASSOCIATES
Entity Type:Organization
Organization Name:A REZVAN MD SC AND ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDOLMAJID
Authorized Official - Middle Name:T
Authorized Official - Last Name:REZVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-235-0800
Mailing Address - Street 1:1921 N HARLEM AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60707-3740
Mailing Address - Country:US
Mailing Address - Phone:773-235-0800
Mailing Address - Fax:847-657-1622
Practice Address - Street 1:1921 N HARLEM AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60707-3740
Practice Address - Country:US
Practice Address - Phone:773-235-0800
Practice Address - Fax:847-657-1622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTIN
IL901420Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
ILD12408Medicare UPIN