MEDICARE: KOOSHA MEDICAL CENTER P C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0360856071	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164711644
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOOSHA MEDICAL CENTER P C

Provider Business Mailing Address
First Line	:	4438 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-3743
Country	:	US
Telephone Number	:	773-794-2100
Fax Number	:

Provider Business Practice Location Address
First Line	:	4438 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-3743
Country	:	US
Telephone Number	:	773-794-2100
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EBRAHIM GHODSIZADEH
Credential	:	M.D.
Telephone Number	:	773-794-2100

Provider Enumeration Date	:	04/05/2011
Last Update Date	:	03/07/2023

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Directions to “KOOSHA MEDICAL CENTER P C ” Practice Location

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