Provider Demographics
NPI:1790893881
Name:FAKOURI, FARAH
Entity type:Individual
Prefix:
First Name:FARAH
Middle Name:
Last Name: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 1:2734 W 87TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-3937
Mailing Address - Country:US
Mailing Address - Phone:773-918-4700
Mailing Address - Fax:773-313-3763
Practice Address - Street 1:2734 W 87TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-3937
Practice Address - Country:US
Practice Address - Phone:773-918-4700
Practice Address - Fax:773-313-3763
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI83655207RI0200X
IL036089264207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00708155OtherRR MEDICARE PTAN (INDIVIDUAL)
IL206147OtherMEDICARE PTAN (GROUP)
IL036089264Medicaid
WI1790893881Medicaid
ILK53368OtherMEDICARE PTAN (INDIVIDUAL)