Provider Demographics
NPI:1366083032
Name:RAMIN GHAZIZADEH LLC
Entity type:Organization
Organization Name:RAMIN GHAZIZADEH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GHAZIZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:312-330-4574
Mailing Address - Street 1:231 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-2097
Mailing Address - Country:US
Mailing Address - Phone:708-748-3338
Mailing Address - Fax:708-748-4332
Practice Address - Street 1:231 MAIN ST
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2097
Practice Address - Country:US
Practice Address - Phone:708-748-3338
Practice Address - Fax:708-748-4332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-03
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005783Medicaid