Healthcare Provider Details

I. General information

NPI: 1992381479
Provider Name (Legal Business Name): GHASSAN JEAN FARAH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 W DIVERSEY PKWY RM 300
CHICAGO IL
60614-1454
US

IV. Provider business mailing address

835 S WOLCOTT AVE RM E-270
CHICAGO IL
60612-3748
US

V. Phone/Fax

Practice location:
  • Phone: 773-248-4150
  • Fax: 773-248-4291
Mailing address:
  • Phone: 312-996-9858
  • Fax: 312-996-9025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: