Healthcare Provider Details

I. General information

NPI: 1821112046
Provider Name (Legal Business Name): MOHIN T SAMARAWEERA MD SC PLAINFIELD MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24016 W MAIN ST
PLAINFIELD IL
60544-2232
US

IV. Provider business mailing address

24016 W MAIN ST
PLAINFIELD IL
60544-2232
US

V. Phone/Fax

Practice location:
  • Phone: 815-436-7303
  • Fax: 815-609-7980
Mailing address:
  • Phone: 815-436-7303
  • Fax: 815-609-7980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number36048836
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9900490
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBC BS OF IL

VIII. Authorized Official

Name: MOHIN TISSA SAMARAWEERA
Title or Position: DIRECTOR
Credential: MD
Phone: 815-436-7303