Healthcare Provider Details

I. General information

NPI: 1770147480
Provider Name (Legal Business Name): RUSTAM SAFAROV FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2019
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 N MILWAUKEE AVE
WHEELING IL
60090-3012
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 800-323-8622
  • Fax:
Mailing address:
  • Phone: 847-390-5900
  • Fax: 847-390-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF03190845
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.019746
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: