Healthcare Provider Details

I. General information

NPI: 1447954920
Provider Name (Legal Business Name): KIRAN NIZAMANI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 RIVERSIDE DR STE 2100
BOURBONNAIS IL
60914-5004
US

IV. Provider business mailing address

400 RIVERSIDE DR STE 2100
BOURBONNAIS IL
60914-5004
US

V. Phone/Fax

Practice location:
  • Phone: 815-935-2784
  • Fax:
Mailing address:
  • Phone: 815-935-2784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036180269
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: