Provider Demographics
NPI:1992828339
Name:SOROURI, MEHRAN R (DC, DACO, CCSP)
Entity Type:Individual
Prefix:DR
First Name:MEHRAN
Middle Name:R
Last Name:SOROURI
Suffix:
Gender:M
Credentials:DC, DACO, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 W BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6467
Mailing Address - Country:US
Mailing Address - Phone:773-525-8100
Mailing Address - Fax:773-525-8130
Practice Address - Street 1:2051 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6467
Practice Address - Country:US
Practice Address - Phone:773-525-8100
Practice Address - Fax:773-525-8130
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009498111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1632755OtherBCBS
IL1632755OtherBCBS
IL204174Medicare ID - Type Unspecified