Healthcare Provider Details

I. General information

NPI: 1154185387
Provider Name (Legal Business Name): MOHAMMED ABDUL MANNAN ANSARI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7350 W COLLEGE DR STE 103
PALOS HEIGHTS IL
60463-1187
US

IV. Provider business mailing address

8127 MERRILLVILLE RD STE 1
MERRILLVILLE IN
46410-6306
US

V. Phone/Fax

Practice location:
  • Phone: 708-694-9876
  • Fax:
Mailing address:
  • Phone: 219-208-6218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.010291
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: