Healthcare Provider Details

I. General information

NPI: 1215432596
Provider Name (Legal Business Name): MOHAMMED ABDULQAWI SIDDIQUI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 N BROAD ST
PHILADELPHIA PA
19122-6003
US

IV. Provider business mailing address

7202 EDGEBROOK LN
HANOVER PARK IL
60133-3751
US

V. Phone/Fax

Practice location:
  • Phone: 847-845-7356
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036.160471
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: