=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639790884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICIANS AT YOUR HOME, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2020
-----------------------------------------------------
Last Update Date | 05/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1629 N NATCHEZ AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60707-4023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-926-4225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 722 N EMROY AVE
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-926-4225
-----------------------------------------------------
Fax | 708-401-1556
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FNP-C
-----------------------------------------------------
Name | HABIBA SEIDU-FUSEINI
-----------------------------------------------------
Credential | APN
-----------------------------------------------------
Telephone | 309-264-2256
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------