Provider Demographics
NPI:1154977478
Name:HADI, SUROOSH
Entity type:Individual
Prefix:MS
First Name:SUROOSH
Middle Name:
Last Name:HADI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 ORLAND SQUARE DR STE 203
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-6559
Mailing Address - Country:US
Mailing Address - Phone:708-460-3235
Mailing Address - Fax:708-460-3994
Practice Address - Street 1:62 ORLAND SQUARE DR STE 203
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-6559
Practice Address - Country:US
Practice Address - Phone:708-460-3235
Practice Address - Fax:708-460-3994
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1010891251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1010891OtherLICENSE