Healthcare Provider Details

I. General information

NPI: 1629271853
Provider Name (Legal Business Name): KUROSH TAKHTEHCHIAN D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

1740 W TAYLOR ST STE 3200
CHICAGO IL
60612-7232
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-4020
  • Fax:
Mailing address:
  • Phone: 312-996-4020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036109557
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number036109557
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036109557
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number036-109557
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: