Healthcare Provider Details

I. General information

NPI: 1467765891
Provider Name (Legal Business Name): MOHAMMED I AHMED SERVICE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2803 W HARRISON ST
CHICAGO IL
60612-3332
US

IV. Provider business mailing address

737 S FAIRFIELD AVE
LOMBARD IL
60148-3503
US

V. Phone/Fax

Practice location:
  • Phone: 773-533-5523
  • Fax: 773-533-1479
Mailing address:
  • Phone: 773-533-5523
  • Fax: 773-533-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036081126
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier036081126
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name: DR. MOHAMMED ISMAIL AHMED
Title or Position: OWNER
Credential: M.D.
Phone: 773-533-5523