Healthcare Provider Details

I. General information

NPI: 1932574514
Provider Name (Legal Business Name): OWAIZ ANSARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MR. OWAIS ANSARI

II. Dates (important events)

Enumeration Date: 12/07/2015
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE STE 1304
EVANSTON IL
60201-1700
US

IV. Provider business mailing address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2000
  • Fax:
Mailing address:
  • Phone: 847-570-2475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036160950
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number125.073828
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: