Healthcare Provider Details

I. General information

NPI: 1336593714
Provider Name (Legal Business Name): SMCCS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 10/24/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 W LAKE ST UNIT 3
ROSELLE IL
60172-3551
US

IV. Provider business mailing address

490 W LAKE ST UNIT 3
ROSELLE IL
60172-3551
US

V. Phone/Fax

Practice location:
  • Phone: 630-550-7252
  • Fax: 866-656-1698
Mailing address:
  • Phone: 630-550-7252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: NOOR FATIMA HUSAIN
Title or Position: CEO
Credential: M.D.
Phone: 630-550-7252