=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669433280
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMMAD FAROOQ MS.PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5TH AND ROOSELVET RD HINES VA HOSPITAL
-----------------------------------------------------
City | HINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-202-4365
-----------------------------------------------------
Fax | 708-202-2386
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1104 EAST HIGHRIDGE RD
-----------------------------------------------------
City | LOMABRD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-953-0830
-----------------------------------------------------
Fax | 708-202-2386
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------