Healthcare Provider Details

I. General information

NPI: 1679561260
Provider Name (Legal Business Name): JESSE BROWN VETERANS ADMINISTRATION HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2005
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S DAMEN AVE
CHICAGO IL
60612-3728
US

IV. Provider business mailing address

950 N CLARK ST UNIT K.,
CHICAGO IL
60610-8701
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-6123
  • Fax: 312-569-8102
Mailing address:
  • Phone: 312-280-1840
  • Fax: 312-280-4546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number036066117
License Number StateIL

VIII. Authorized Official

Name: DR. FARIDA AHMED
Title or Position: STAFF RADIOLOGIST
Credential: M.D.
Phone: 312-569-6123