Provider Demographics
NPI:1063450757
Name:PAHLAVAN, PEYMAN (MD)
Entity type:Individual
Prefix:DR
First Name:PEYMAN
Middle Name:
Last Name:PAHLAVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 1/2 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160
Mailing Address - Country:US
Mailing Address - Phone:312-371-9325
Mailing Address - Fax:708-345-8965
Practice Address - Street 1:153 1/2 N. BROADWAY AVENUE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160
Practice Address - Country:US
Practice Address - Phone:708-345-8960
Practice Address - Fax:708-345-8965
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-103944207RG0300X
IL036103944207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-103944Medicaid
IL0001634278OtherBLUE CROSS & BLUE SHIELD
IL0001634278OtherBLUE CROSS & BLUE SHIELD
IL036-103944Medicaid