Healthcare Provider Details

I. General information

NPI: 1972044113
Provider Name (Legal Business Name): FADDI GHASSAN MOHAMMED SALEH VELEZ M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE # MC2030
CHICAGO IL
60637
US

IV. Provider business mailing address

180 HARVESTER DR STE 110
BURR RIDGE IL
60527-6686
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-6222
  • Fax:
Mailing address:
  • Phone: 737-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberME149289
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number125.071805
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: