Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2081S0010X | Sports Medicine | 01076001A | IN |
N | 213ES0000X | Sports Medicine | 01076001A | IN |
Y | 2081S0010X | Sports Medicine | 036.096469 | IL |
Y | 213ES0000X | Sports Medicine | 036.096469 | IL |
NPI | 1265751127 |
---|---|
Provider Name | Leda Ameri Ghannad |
First Address | Westchester, IL 60154-5701 |
Second Address | Munster, IN 46321-2885 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/05/2010 |
Last Update Date | 08/12/2016 |