Healthcare Provider Details

I. General information

NPI: 1780008300
Provider Name (Legal Business Name): LIBERTY ANESTHESIA & PAIN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2014
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1634 AVENUE OF THE CITIES
MOLINE IL
61265-4860
US

IV. Provider business mailing address

5530 RIVER PARK DR
LIBERTYVILLE IL
60048-4204
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-9711
  • Fax: 309-762-9747
Mailing address:
  • Phone: 847-281-7235
  • Fax: 847-409-0410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036083169
License Number StateIL

VIII. Authorized Official

Name: MOHAMMAD I HUSSAIN
Title or Position: OWNER
Credential: MD
Phone: 847-409-0410