Healthcare Provider Details

I. General information

NPI: 1770928640
Provider Name (Legal Business Name): SHOEB MOHIUDDIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2013
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1658 N MILWAUKEE AVE # 295
CHICAGO IL
60647-6905
US

IV. Provider business mailing address

1740 W TAYLOR ST 3200W UIH M/C515
CHICAGO IL
60612-7232
US

V. Phone/Fax

Practice location:
  • Phone: 312-300-3882
  • Fax:
Mailing address:
  • Phone: 312-996-4021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036140752
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036140752
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: