MEDICARE: MOHAMMAD TABATABAEI P.A.-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	085-002332	IL

General Provider Information

NPI Number	:	1215954813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOHAMMAD TABATABAEI P.A.-C

Provider Business Mailing Address
First Line	:	2300 N EDWARD ST
Second Line	:	GSBLL
City	:	DECATUR
State	:	IL
Zip	:	62526-4163
Country	:	US
Telephone Number	:	217-876-2857
Fax Number	:	217-876-2874

Provider Business Practice Location Address
First Line	:	1220 W JACKSON ST
Second Line	:
City	:	SULLIVAN
State	:	IL
Zip	:	61951-1032
Country	:	US
Telephone Number	:	217-728-2042
Fax Number	:	217-728-2485

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	01/10/2023

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