MEDICARE: DR. EBRAHIM GHODSIZADEH 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	207Q00000X	Family Medicine Physician		IL

General Provider Information

NPI Number	:	1972523892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EBRAHIM GHODSIZADEH MD

Provider Business Mailing Address
First Line	:	4438 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-3743
Country	:	US
Telephone Number	:	773-794-2100
Fax Number	:	773-794-2492

Provider Business Practice Location Address
First Line	:	4438 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-3743
Country	:	US
Telephone Number	:	773-794-2100
Fax Number	:	773-794-2492

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

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	03/07/2023

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