Healthcare Provider Details

I. General information

NPI: 1376905620
Provider Name (Legal Business Name): POUYA JAMSHIDI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 N FAIRBANKS CT STE 2-458
CHICAGO IL
60611-3013
US

IV. Provider business mailing address

710 N FAIRBANKS CT STE 2-458
CHICAGO IL
60611-3013
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-3211
  • Fax: 312-503-8259
Mailing address:
  • Phone: 312-926-3211
  • Fax: 312-503-8259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number036155214
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number125.072322
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: