Provider Demographics
NPI:1780788968
Name:COHANIM, NOOSHIN SALLY (MD)
Entity type:Individual
Prefix:
First Name:NOOSHIN
Middle Name:SALLY
Last Name:COHANIM
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 1:1460 N HALSTED ST STE 202
Mailing Address - Street 2:PRIMARY CARE MEDICAL ASSOCIATES LTD
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-2605
Mailing Address - Country:US
Mailing Address - Phone:773-871-4409
Mailing Address - Fax:773-871-3608
Practice Address - Street 1:1460 N HALSTED ST STE 202
Practice Address - Street 2:PRIMARY CARE MEDICAL ASSOCIATES LTD
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2605
Practice Address - Country:US
Practice Address - Phone:773-871-4409
Practice Address - Fax:773-871-3608
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036103703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103703Medicaid
IL036103703Medicaid
K19716Medicare ID - Type Unspecified