MEDICARE: INNER-CITY MUSLIM ACTION NETWORK

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	261QF0400X	Federally Qualified Health Center (FQHC)		IL

General Provider Information

NPI Number	:	1396238937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNER-CITY MUSLIM ACTION NETWORK

Provider Business Mailing Address
First Line	:	2744 W. 63RD STREET
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629
Country	:	US
Telephone Number	:	773-434-4626
Fax Number	:	773-303-8858

Provider Business Practice Location Address
First Line	:	2749 W 63RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-2342
Country	:	US
Telephone Number	:	773-434-4626
Fax Number	:	773-303-8858

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	RAMI NASHASHIBI
Credential	:
Telephone Number	:	773-434-4626

Provider Enumeration Date	:	06/08/2018
Last Update Date	:	06/08/2018

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