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General NPI Number Information
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NPI Number | 1205292281
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Entity Type | Organization
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Legal Business Name | MJM MEDICAL CORP
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Dates
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Enumeration Date | 01/07/2016
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Last Update Date | 01/07/2016
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Provider Practice Location Address
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Address Line | 5696 HEIDI DR
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City | ROCKFORD
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State | IL
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Zip | 61109-1768
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Country | US
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Telephone | 224-412-1720
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Fax |
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Provider Business Mailing Address
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Address Line | 5696 HEIDI DR
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City | ROCKFORD
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State | IL
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Zip | 61109-1768
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Country | US
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Telephone | 224-412-1720
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MOHAMMAD MIRAN
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Credential | D.O.
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Telephone | 224-412-1720
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RS0012X
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Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
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License Number | 036-127728
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License Number State | IL
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