Healthcare Provider Details

I. General information

NPI: 1386945012
Provider Name (Legal Business Name): NORTHSIDE HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 11/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9120 W GOLF RD
NILES IL
60714-5806
US

IV. Provider business mailing address

9120 W GOLF RD
NILES IL
60714-5806
US

V. Phone/Fax

Practice location:
  • Phone: 847-390-7083
  • Fax: 847-390-7115
Mailing address:
  • Phone: 847-390-7083
  • Fax: 847-390-7115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: ANWAR M MOHIUDDIN
Title or Position: DIRECTOR
Credential: M.D.
Phone: 847-390-7083