Healthcare Provider Details

I. General information

NPI: 1568209880
Provider Name (Legal Business Name): MSO ILLINOIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 W COLLEGE DR STE 100
PALOS HEIGHTS IL
60463-1789
US

IV. Provider business mailing address

6400 W COLLEGE DR STE 100
PALOS HEIGHTS IL
60463-1789
US

V. Phone/Fax

Practice location:
  • Phone: 253-335-5150
  • Fax: 253-984-1079
Mailing address:
  • Phone: 253-335-5150
  • Fax: 253-984-1079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MUAHMMAD NAZIR
Title or Position: OWNER
Credential:
Phone: 253-335-5150