Provider Demographics
NPI:1144495144
Name:RAD GHARAVI MD PC
Entity type:Organization
Organization Name:RAD GHARAVI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAD
Authorized Official - Middle Name:
Authorized Official - Last Name:GHARAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-790-5200
Mailing Address - Street 1:6551 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1020
Mailing Address - Country:US
Mailing Address - Phone:708-790-5200
Mailing Address - Fax:708-524-2104
Practice Address - Street 1:6551 NORTH AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1020
Practice Address - Country:US
Practice Address - Phone:708-790-5200
Practice Address - Fax:708-524-2104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-1033222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6061502Medicaid
IL590950Medicare PIN
ILH21982Medicare UPIN