MEDICARE: MUNA AHMED ELFAKI MOHAMAD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	125078696	IL
2	208M00000X	Hospitalist Physician	DR0072638	CO

General Provider Information

NPI Number	:	1154099976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MUNA AHMED ELFAKI MOHAMAD

Provider Business Mailing Address
First Line	:	2800 N LAKE SHORE DR APT 3111
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-6275
Country	:	US
Telephone Number	:	773-543-6014
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 W 16TH ST
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81003
Country	:	US
Telephone Number	:	719-584-4921
Fax Number	:	719-595-7994

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2021
Last Update Date	:	04/26/2024

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