Provider Demographics
NPI:1649763624
Name:FARGOTSTEIN, ALYSSA KAHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ALYSSA
Middle Name:KAHAN
Last Name:FARGOTSTEIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 W RAND RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-2315
Mailing Address - Country:US
Mailing Address - Phone:847-221-4900
Mailing Address - Fax:847-221-4996
Practice Address - Street 1:1051 W RAND RD STE 101
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-2315
Practice Address - Country:US
Practice Address - Phone:847-221-4900
Practice Address - Fax:847-221-4996
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.072245207V00000X
IL036156058207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036156058OtherSTATE LICENSE