Provider Demographics
NPI:1679561260
Name:JESSE BROWN VETERANS ADMINISTRATION HOSPITAL
Entity Type:Organization
Organization Name:JESSE BROWN VETERANS ADMINISTRATION HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF RADIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FARIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-569-6123
Mailing Address - Street 1:950 N CLARK ST
Mailing Address - Street 2:UNIT K.,
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-8701
Mailing Address - Country:US
Mailing Address - Phone:312-280-1840
Mailing Address - Fax:312-280-4546
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-569-6123
Practice Address - Fax:312-569-8102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-09
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066117282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access