MEDICARE: DR. KOUROSH DINI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	102L00000X	Psychoanalyst		IL
2	2084P0800X	Psychiatry Physician	036107898	IL
3	2084P0804X	Child & Adolescent Psychiatry Physician	036107898	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	01635637	OTHER		BC/BS

General Provider Information

NPI Number	:	1346256245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KOUROSH DINI MD

Provider Business Mailing Address
First Line	:	1020 S WABASH AVE APT 4G
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-2255
Country	:	US
Telephone Number	:	312-391-3171
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 S WABASH AVE APT 4G
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-2255
Country	:	US
Telephone Number	:	312-391-3171
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	12/03/2024

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