Healthcare Provider Details

I. General information

NPI: 1447746466
Provider Name (Legal Business Name): HUMNA FAYYAZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 W FOSTER AVE STE 113
CHICAGO IL
60625-3547
US

IV. Provider business mailing address

2740 W FOSTER AVE STE 113
CHICAGO IL
60625-3547
US

V. Phone/Fax

Practice location:
  • Phone: 773-293-5300
  • Fax: 773-293-5346
Mailing address:
  • Phone: 773-293-5300
  • Fax: 773-293-5346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number036167720
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number036167720
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberLL52802
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number036167720
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: