Healthcare Provider Details

I. General information

NPI: 1396219176
Provider Name (Legal Business Name): MOHAMMAD JAMAL DEEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 08/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

V. Phone/Fax

Practice location:
  • Phone: 170-878-3910
  • Fax:
Mailing address:
  • Phone: 917-353-0245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WF0300X
TaxonomyFlight Registered Nurse
License Number041423146
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001137
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209018755
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: