Healthcare Provider Details

I. General information

NPI: 1265194120
Provider Name (Legal Business Name): ANSAR A MOHAMMED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 05/16/2024
Certification Date: 10/09/2021
Deactivation Date: 10/09/2021
Reactivation Date: 05/16/2024

III. Provider practice location address

6424 N ARTESIAN AVE
CHICAGO IL
60645-5356
US

IV. Provider business mailing address

6424 N ARTESIAN AVE
CHICAGO IL
60645-5356
US

V. Phone/Fax

Practice location:
  • Phone: 773-852-7866
  • Fax:
Mailing address:
  • Phone: 773-852-7866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: