Healthcare Provider Details

I. General information

NPI: 1356074264
Provider Name (Legal Business Name): MIDWEST PRIMARY CARE AND GERIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 MAPLE AVE STE 4A
LISLE IL
60532-4135
US

IV. Provider business mailing address

1440 MAPLE AVE STE 4A
LISLE IL
60532-4135
US

V. Phone/Fax

Practice location:
  • Phone: 708-420-3169
  • Fax:
Mailing address:
  • Phone: 708-420-3169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NAUSHEEN AHMED
Title or Position: OWNER
Credential:
Phone: 708-420-3169