Healthcare Provider Details

I. General information

NPI: 1902917818
Provider Name (Legal Business Name): FAZAL AHMED MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST ROOM # 3022
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

1901 W HARRISON ST ROOM # 3022
CHICAGO IL
60612-3714
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6007
  • Fax: 312-864-9371
Mailing address:
  • Phone: 312-864-6007
  • Fax: 312-864-9371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036-107430
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036-107430
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: