Healthcare Provider Details

I. General information

NPI: 1366646879
Provider Name (Legal Business Name): MOSTAFA ABDUL-RAHMAN FARACHE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W JACKSON ST STE 103
CARBONDALE IL
62901-1474
US

IV. Provider business mailing address

16513 HAVEN AVE
ORLAND HILLS IL
60487-5637
US

V. Phone/Fax

Practice location:
  • Phone: 618-351-4972
  • Fax: 618-351-6522
Mailing address:
  • Phone: 218-786-8364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036158130
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberW0804
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number50637
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2025024854
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: