=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861956849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED CARE SPECIALIST GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2019
-----------------------------------------------------
Last Update Date | 01/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5907 W 63RD ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60638-5409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-843-3308
-----------------------------------------------------
Fax | 708-590-6948
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 ORLAND SQUARE DR STE A
-----------------------------------------------------
City | ORLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60462-3207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-949-8904
-----------------------------------------------------
Fax | 708-590-6948
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MOHAMAD R ALZEIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 708-843-3308
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------