Healthcare Provider Details

I. General information

NPI: 1376986547
Provider Name (Legal Business Name): MUHANNED GHIRRI RSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 04/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 W PETERSON AVE
CHICAGO IL
60659-5203
US

IV. Provider business mailing address

2320 W PETERSON AVE ATTN:VANESSA CASTORENA
CHICAGO IL
60659-5242
US

V. Phone/Fax

Practice location:
  • Phone: 773-508-9300
  • Fax: 773-761-2112
Mailing address:
  • Phone: 773-508-9800
  • Fax: 773-508-1796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number238000338
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: