Healthcare Provider Details

I. General information

NPI: 1700518149
Provider Name (Legal Business Name): DR. MOHAMMAD AL NOBANI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2022
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST FL 5
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

2373 WALBORN DR
HILLIARD OH
43026-8772
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-1905
  • Fax:
Mailing address:
  • Phone: 614-822-5069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125.080145
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: