Healthcare Provider Details

I. General information

NPI: 1063405223
Provider Name (Legal Business Name): MUJAHID MOHAMMAD HUSSAIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 GATEWAY DR
SYCAMORE IL
60178-3192
US

IV. Provider business mailing address

1850 GATEWAY DR
SYCAMORE IL
60178-3192
US

V. Phone/Fax

Practice location:
  • Phone: 815-756-1521
  • Fax:
Mailing address:
  • Phone: 815-756-1521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036091955
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036091955
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: