Healthcare Provider Details

I. General information

NPI: 1144674706
Provider Name (Legal Business Name): FAIZAN BADER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RIVERSIDE DR
BOURBONNAIS IL
60914-4607
US

IV. Provider business mailing address

100 RIVERSIDE DR
BOURBONNAIS IL
60914-4607
US

V. Phone/Fax

Practice location:
  • Phone: 815-802-7090
  • Fax:
Mailing address:
  • Phone: 815-802-7090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number01005835
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: