Provider Demographics
NPI:1790893881
Name:HASHEMI FAKOURI, FARAH
Entity Type:Individual
Prefix:
First Name:FARAH
Middle Name:
Last Name:HASHEMI FAKOURI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FARAH
Other - Middle Name:
Other - Last Name:HASHEMI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-933-1199
Mailing Address - Fax:630-933-4558
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-933-1199
Practice Address - Fax:630-933-4558
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101311207RI0200X
IL036089264207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089264Medicaid
ILK53368OtherMEDICARE PTAN (INDIVIDUAL)
ILP00708155OtherRR MEDICARE PTAN (INDIVIDUAL)
IL206147OtherMEDICARE PTAN (GROUP)
ILP00708155OtherRR MEDICARE PTAN (INDIVIDUAL)