Healthcare Provider Details

I. General information

NPI: 1033208897
Provider Name (Legal Business Name): MOHAMMAD REZA S ASHRAF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 20TH ST
GRANITE CITY IL
62040-4607
US

IV. Provider business mailing address

1420 20TH ST
GRANITE CITY IL
62040-4607
US

V. Phone/Fax

Practice location:
  • Phone: 618-877-8200
  • Fax: 618-877-8206
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036048540
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: