Provider Demographics
NPI:1265767537
Name:ABDOL HOSSEINIAN MD
Entity type:Organization
Organization Name:ABDOL HOSSEINIAN MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDOL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOSSEINIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-404-0160
Mailing Address - Street 1:4250 N MARINE DR
Mailing Address - Street 2:SUITE 236
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1744
Mailing Address - Country:US
Mailing Address - Phone:773-404-0160
Mailing Address - Fax:773-404-9876
Practice Address - Street 1:4250 N MARINE DR
Practice Address - Street 2:SUITE 236
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1744
Practice Address - Country:US
Practice Address - Phone:773-404-0160
Practice Address - Fax:773-404-9876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360440385207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036044385Medicaid
IL036044385Medicaid