Healthcare Provider Details

I. General information

NPI: 1972036929
Provider Name (Legal Business Name): MEHRDAD NIROUMANDPOUR DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

320 EVERGREEN CT
SCHAUMBURG IL
60193-1558
US

V. Phone/Fax

Practice location:
  • Phone: 847-361-6698
  • Fax:
Mailing address:
  • Phone: 847-361-6698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number324193
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number324193
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: