Healthcare Provider Details

I. General information

NPI: 1033539630
Provider Name (Legal Business Name): MOHAMMAD ABDELHAFEZ ISSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RIVERSIDE DR
BOURBONNAIS IL
60914-4607
US

IV. Provider business mailing address

100 RIVERSIDE DR
BOURBONNAIS IL
60914-4607
US

V. Phone/Fax

Practice location:
  • Phone: 815-802-7090
  • Fax: 815-802-7091
Mailing address:
  • Phone: 815-802-7090
  • Fax: 815-802-7091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036148856
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number036148856
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number036148856
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: