Healthcare Provider Details

I. General information

NPI: 1639354780
Provider Name (Legal Business Name): LIBERTY MEDICAL CENTER OF MINOOKA, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 W MONDAMIN ST
MINOOKA IL
60447-9057
US

IV. Provider business mailing address

603 W MONDAMIN ST
MINOOKA IL
60447-9057
US

V. Phone/Fax

Practice location:
  • Phone: 815-521-1010
  • Fax: 815-521-1826
Mailing address:
  • Phone: 815-521-1010
  • Fax: 815-521-1826

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 Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AFTAB A KHAN
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 815-521-1010