Healthcare Provider Details

I. General information

NPI: 1124086012
Provider Name (Legal Business Name): SHAHROKH N KAYHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20201 CRAWFORD AVE SUITE 1276
OLYMPIA FIELDS IL
60461-1010
US

IV. Provider business mailing address

1040 SIERRA DR SUITE 400
GREENWOOD IN
46143-7240
US

V. Phone/Fax

Practice location:
  • Phone: 555-555-5555
  • Fax: 555-555-5554
Mailing address:
  • Phone: 555-555-5555
  • Fax: 555-555-5554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036053401
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: