Healthcare Provider Details

I. General information

NPI: 1730421306
Provider Name (Legal Business Name): MARYAM SHIRAZI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2013
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

622 W 168TH ST
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-0419
  • Fax:
Mailing address:
  • Phone: 347-408-8494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036149334
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: