Healthcare Provider Details

I. General information

NPI: 1811102353
Provider Name (Legal Business Name): MEDICAL CARE CENTER OF LAKE VILLA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 S MILWAUKEE AVE
LAKE VILLA IL
60046-8551
US

IV. Provider business mailing address

213 S MILWAUKEE AVE
LAKE VILLA IL
60046-8551
US

V. Phone/Fax

Practice location:
  • Phone: 847-356-9009
  • Fax:
Mailing address:
  • Phone: 847-356-9009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036058768
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036082737
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036047948
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036058768
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036082737
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number036058768
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number036058768
License Number StateIL
# 8
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036058768
License Number StateIL
# 9
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036047948
License Number StateIL
# 10
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036058768
License Number StateIL
# 11
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036082737
License Number StateIL
# 12
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036047948
License Number StateIL
# 13
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036047948
License Number StateIL

VIII. Authorized Official

Name: DR. MOHAMED E NASR
Title or Position: PHYSICIAN AND SURGEON
Credential: M.D.
Phone: 847-356-9009