Healthcare Provider Details

I. General information

NPI: 1699396838
Provider Name (Legal Business Name): ASHIF KHALED MOLLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SILVER CROSS BLVD
NEW LENOX IL
60451-9509
US

IV. Provider business mailing address

OSF ST FRANCIS MEDICAL CENTER 530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

V. Phone/Fax

Practice location:
  • Phone: 708-478-7201
  • Fax: 708-221-6766
Mailing address:
  • Phone: 309-624-9351
  • Fax:

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 StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.166116
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: