MEDICARE: MOHAMMED ABDUL MANNAN ANSARI PA-C

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	363A00000X	Physician Assistant	085.010291	IL

General Provider Information

NPI Number	:	1154185387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOHAMMED ABDUL MANNAN ANSARI PA-C

Provider Business Mailing Address
First Line	:	29373 NETWORK PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-1293
Country	:	US
Telephone Number	:	847-390-5900
Fax Number	:

Provider Business Practice Location Address
First Line	:	7350 W COLLEGE DR STE 103
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1187
Country	:	US
Telephone Number	:	708-694-9876
Fax Number	:

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

Provider Enumeration Date	:	02/08/2024
Last Update Date	:	02/19/2026

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