Healthcare Provider Details

I. General information

NPI: 1205292281
Provider Name (Legal Business Name): MJM MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2016
Last Update Date: 01/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5696 HEIDI DR
ROCKFORD IL
61109-1768
US

IV. Provider business mailing address

5696 HEIDI DR
ROCKFORD IL
61109-1768
US

V. Phone/Fax

Practice location:
  • Phone: 224-412-1720
  • Fax:
Mailing address:
  • Phone: 224-412-1720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number036-127728
License Number StateIL

VIII. Authorized Official

Name: MOHAMMAD MIRAN
Title or Position: CEO
Credential: D.O.
Phone: 224-412-1720