Healthcare Provider Details

I. General information

NPI: 1598247090
Provider Name (Legal Business Name): MIRA AKBAR EBALO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 WAUKEGAN RD STE 210
MORTON GROVE IL
60053-2127
US

IV. Provider business mailing address

4157 N CLARENDON AVE APT 512
CHICAGO IL
60613-2249
US

V. Phone/Fax

Practice location:
  • Phone: 847-967-5122
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.006738
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085.006738
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085.006738
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: