Healthcare Provider Details

I. General information

NPI: 1942788302
Provider Name (Legal Business Name): SYED MANSURUL HAQUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2018
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2231 E 95TH ST
CHICAGO IL
60617-4804
US

IV. Provider business mailing address

2231 E 95TH ST
CHICAGO IL
60617-4804
US

V. Phone/Fax

Practice location:
  • Phone: 773-768-7700
  • Fax: 773-273-8915
Mailing address:
  • Phone: 773-768-7700
  • Fax: 773-273-8915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number8277
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036160915
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: