MEDICARE: IDA MOLAVI

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	2086S0102X	Surgical Critical Care Physician	036-168562	IL
2	208600000X	Surgery Physician	321181	LA
3	2086S0127X	Trauma Surgery Physician	036168562	IL
4	208600000X	Surgery Physician	036-168562	IL

General Provider Information

NPI Number	:	1730663907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IDA MOLAVI

Provider Business Mailing Address
First Line	:	29373 NETWORK PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-1293
Country	:	US
Telephone Number	:	847-390-5900
Fax Number	:

Provider Business Practice Location Address
First Line	:	836 W WELLINGTON AVE RM 4813CC
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-5147
Country	:	US
Telephone Number	:	773-296-5073
Fax Number	:	773-296-7199

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

Provider Enumeration Date	:	09/24/2018
Last Update Date	:	02/05/2026

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Directions to “ IDA MOLAVI ” Practice Location

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