MEDICARE: ST MARY INTERNAL MEDICINE ASSOCIATES S 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	261QP2300X	Primary Care Clinic/Center	036094077	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710009204
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST MARY INTERNAL MEDICINE ASSOCIATES S C

Provider Business Mailing Address
First Line	:	2320 S ROUTE 59
Second Line	:
City	:	PLAINFIELD
State	:	IL
Zip	:	60586-7756
Country	:	US
Telephone Number	:	815-609-9480
Fax Number	:	815-609-9482

Provider Business Practice Location Address
First Line	:	2320 S ROUTE 59
Second Line	:
City	:	PLAINFIELD
State	:	IL
Zip	:	60586-7756
Country	:	US
Telephone Number	:	815-609-9480
Fax Number	:	815-609-9482

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ASHRAF ASSAAD ISKANDER
Credential	:	MD
Telephone Number	:	815-609-9480

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	11/30/2010

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