Healthcare Provider Details

I. General information

NPI: 1588977557
Provider Name (Legal Business Name): AMMAR Y DIVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2010
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 S GARY AVE STE 100
BLOOMINGDALE IL
60108-2200
US

IV. Provider business mailing address

245 S GARY AVE STE 100
BLOOMINGDALE IL
60108-2200
US

V. Phone/Fax

Practice location:
  • Phone: 630-933-4550
  • Fax: 630-933-2200
Mailing address:
  • Phone: 630-933-4550
  • Fax: 630-933-2200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036123274
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0101247908
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberD71131
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number068143
License Number StateGA
# 5
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036123274
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: