Healthcare Provider Details

I. General information

NPI: 1568524312
Provider Name (Legal Business Name): LAEEQ S SHAMSUDDIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 W MEDICAL CENTER DR
MCHENRY IL
60050-8409
US

IV. Provider business mailing address

4201 W MEDICAL CENTER DR
MCHENRY IL
60050-8409
US

V. Phone/Fax

Practice location:
  • Phone: 815-759-4530
  • Fax: 815-759-8053
Mailing address:
  • Phone: 815-759-4530
  • Fax: 815-759-8053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036110261
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036110261
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: