Healthcare Provider Details

I. General information

NPI: 1396238937
Provider Name (Legal Business Name): INNER-CITY MUSLIM ACTION NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2749 W 63RD ST
CHICAGO IL
60629-2342
US

IV. Provider business mailing address

2744 W. 63RD STREET
CHICAGO IL
60629
US

V. Phone/Fax

Practice location:
  • Phone: 773-434-4626
  • Fax: 773-303-8858
Mailing address:
  • Phone: 773-434-4626
  • Fax: 773-303-8858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateIL

VIII. Authorized Official

Name: RAMI NASHASHIBI
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 773-434-4626