Healthcare Provider Details

I. General information

NPI: 1952807711
Provider Name (Legal Business Name): FADY MOHAMMED MOUSA-IBRAHIM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

4201 W MEDICAL CENTER DR
MCHENRY IL
60050-8409
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-2687
  • Fax: 708-216-5617
Mailing address:
  • Phone: 815-759-4530
  • Fax: 815-759-8053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number036159688
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: