Healthcare Provider Details

I. General information

NPI: 1821150442
Provider Name (Legal Business Name): AYESHA IMRAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 GREEN BAY RD BLDG 71F
NORTH CHICAGO IL
60064-3048
US

IV. Provider business mailing address

3001 GREEN BAY RD BLDG 71F
NORTH CHICAGO IL
60064-3048
US

V. Phone/Fax

Practice location:
  • Phone: 224-610-3365
  • Fax: 224-610-3852
Mailing address:
  • Phone: 224-610-3365
  • Fax: 224-610-3852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036099338
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number036099338
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: