Provider Demographics
NPI:1386615904
Name:AMANI, EBRAHIM (MD)
Entity type:Individual
Prefix:DR
First Name:EBRAHIM
Middle Name:
Last Name:AMANI
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 1:1049 E WILSON ST
Mailing Address - Street 2:SUITE 160B
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-2474
Mailing Address - Country:US
Mailing Address - Phone:630-232-2776
Mailing Address - Fax:
Practice Address - Street 1:1049 E WILSON ST
Practice Address - Street 2:SUITE 160B
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-2474
Practice Address - Country:US
Practice Address - Phone:630-232-2776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-95344208D00000X
IL3695344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01160490OtherMEDICARE RAIL ROAD PTAN (INDIVIDUAL)
IL036095344Medicaid
IL920540OtherMEDICARE PTAN (GROUP)
IL920540035OtherMEDICARE PTAN (INDIVIDUAL)
ILCA4748OtherMEDICARE RAIL ROAD PTAN (GROUP)
ILCA4748OtherMEDICARE RAIL ROAD PTAN (GROUP)
IL036095344Medicaid