Healthcare Provider Details

I. General information

NPI: 1548308364
Provider Name (Legal Business Name): NORTHSHORE MEDICAL PRACTICE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8118 N MILWAUKEE AVE STE 108
NILES IL
60714-2836
US

IV. Provider business mailing address

92 RIVERSIDE DR
DEERFIELD IL
60015-4868
US

V. Phone/Fax

Practice location:
  • Phone: 847-903-4986
  • Fax: 847-940-0843
Mailing address:
  • Phone: 847-903-4986
  • Fax: 847-940-0843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036096519
License Number StateIL

VIII. Authorized Official

Name: DR. FANAN NIJIN FALOUJI
Title or Position: OWNER
Credential: MD
Phone: 847-903-4986