Healthcare Provider Details

I. General information

NPI: 1033455118
Provider Name (Legal Business Name): ASHLAND MEDICAL SPECIALIST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 W DIVISION ST
CHICAGO IL
60622-8521
US

IV. Provider business mailing address

2041 W DIVISION ST
CHICAGO IL
60622-8521
US

V. Phone/Fax

Practice location:
  • Phone: 312-624-9783
  • Fax: 312-929-3323
Mailing address:
  • Phone: 312-624-9783
  • Fax: 312-929-3323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036103729
License Number StateIL

VIII. Authorized Official

Name: DR. NEEMA BAYRAN
Title or Position: C.E.O.
Credential: M.D.
Phone: 312-624-9783