Healthcare Provider Details

I. General information

NPI: 1710009204
Provider Name (Legal Business Name): ST MARY INTERNAL MEDICINE ASSOCIATES S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 S ROUTE 59
PLAINFIELD IL
60586-7756
US

IV. Provider business mailing address

2320 S ROUTE 59
PLAINFIELD IL
60586-7756
US

V. Phone/Fax

Practice location:
  • Phone: 815-609-9480
  • Fax: 815-609-9482
Mailing address:
  • Phone: 815-609-9480
  • Fax: 815-609-9482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number036094077
License Number StateIL

VII. Legacy identifiers

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

# 1
Identifier036094077
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name: DR. ASHRAF ASSAAD ISKANDER
Title or Position: PRESIDENT
Credential: MD
Phone: 815-609-9480