Healthcare Provider Details

I. General information

NPI: 1710285143
Provider Name (Legal Business Name): ADDISON MEDICAL OFFICE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2011
Last Update Date: 03/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 N ADDISON RD
ADDISON IL
60101-3805
US

IV. Provider business mailing address

11 N ADDISON RD
ADDISON IL
60101-3805
US

V. Phone/Fax

Practice location:
  • Phone: 630-833-5530
  • Fax: 630-833-5560
Mailing address:
  • Phone: 630-833-5530
  • Fax: 630-833-5560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. AYESHA FAREEDUDDIN
Title or Position: OWNER
Credential: MD
Phone: 847-828-3432