Healthcare Provider Details

I. General information

NPI: 1659758092
Provider Name (Legal Business Name): SHOAIB MEMON MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N MICHIGAN AVE SUITE 618
CHICAGO IL
60601-3901
US

IV. Provider business mailing address

333 N MICHIGAN AVE SUITE 618
CHICAGO IL
60601-3901
US

V. Phone/Fax

Practice location:
  • Phone: 708-692-5730
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number036.127359
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.127359
License Number StateIL

VIII. Authorized Official

Name: SHOAIB MEMON
Title or Position: MANAGER
Credential: M.D.
Phone: 708-692-5730