MEDICARE: FANDAH A. HAMDI

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	019.032210	IL

General Provider Information

NPI Number	:	1629620273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FANDAH A. HAMDI

Provider Business Mailing Address
First Line	:	1136 PLEASANT ST APT 2E
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-3043
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1136 PLEASANT ST APT 2E
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-3043
Country	:	US
Telephone Number	:	312-274-4580
Fax Number	:

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

Provider Enumeration Date	:	07/14/2019
Last Update Date	:	07/28/2019

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