Healthcare Provider Details

I. General information

NPI: 1811575145
Provider Name (Legal Business Name): MOHAMED BOSHNAF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 SPRINGHILL DR STE 100
NORTH LITTLE ROCK AR
72117-2905
US

IV. Provider business mailing address

15127 ORLAN BROOK DR APT 3N
ORLAND PARK IL
60462-3951
US

V. Phone/Fax

Practice location:
  • Phone: 501-955-4530
  • Fax:
Mailing address:
  • Phone: 646-226-8505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036168476
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036168476
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: