Healthcare Provider Details

I. General information

NPI: 1336566538
Provider Name (Legal Business Name): THANZEELA KAUSAR MOHIDEEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10215 BROADWAY
CROWN POINT IN
46307-8001
US

IV. Provider business mailing address

1775 BALLARD RD
PARK RIDGE IL
60068-1005
US

V. Phone/Fax

Practice location:
  • Phone: 219-661-6100
  • Fax:
Mailing address:
  • Phone: 847-318-9340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.064632
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number01080587A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: