Healthcare Provider Details

I. General information

NPI: 1629266341
Provider Name (Legal Business Name): MOHAMMAD MUNEEB PURI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W MONTEREY AVE STE 7A
CHICAGO IL
60643-4257
US

IV. Provider business mailing address

210 S DESPLAINES ST
CHICAGO IL
60661-5500
US

V. Phone/Fax

Practice location:
  • Phone: 708-952-3040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036.134881
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: