Healthcare Provider Details

I. General information

NPI: 1063824027
Provider Name (Legal Business Name): GHAZALEH ROSTAMI NIA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9650 GROSS POINT RD STE 3900
SKOKIE IL
60076-5085
US

IV. Provider business mailing address

2650 RIDGE AVENUE WALGREEN BUILDING, SUITE 1507
EVANSTON IL
60201
US

V. Phone/Fax

Practice location:
  • Phone: 224-251-2374
  • Fax: 847-933-3531
Mailing address:
  • Phone: 847-434-9728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116026700
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number0116026700
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number036.142490
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: