Healthcare Provider Details

I. General information

NPI: 1164853388
Provider Name (Legal Business Name): MNM HOME MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2013
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 W JEFFERSON ST
JOLIET IL
60435-6862
US

IV. Provider business mailing address

1325 W JEFFERSON ST
JOLIET IL
60435-6862
US

V. Phone/Fax

Practice location:
  • Phone: 815-744-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036047431
License Number StateIL

VIII. Authorized Official

Name: DR. NAZEER SHAIK
Title or Position: PRESIDENT
Credential: MD
Phone: 815-744-7400