Healthcare Provider Details

I. General information

NPI: 1487055513
Provider Name (Legal Business Name): FAIROAKS MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1254 OGDEN AVE
DOWNERS GROVE IL
60515-2740
US

IV. Provider business mailing address

1254 OGDEN AVE
DOWNERS GROVE IL
60515-2740
US

V. Phone/Fax

Practice location:
  • Phone: 630-963-6912
  • Fax: 630-963-1499
Mailing address:
  • Phone: 630-963-6912
  • Fax: 630-963-1499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. MOHAMMAD VASEEMUDDIN
Title or Position: OWNER
Credential: M.D.
Phone: 630-876-9000