MEDICARE: SOUTH BELOIT OFFICE

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	208D00000X	General Practice Physician	036126253	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679839773
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH BELOIT OFFICE

Provider Business Mailing Address
First Line	:	1407 PATE PLAZA DR
Second Line	:
City	:	SOUTH BELOIT
State	:	IL
Zip	:	61080-1431
Country	:	US
Telephone Number	:	630-219-2002
Fax Number	:

Provider Business Practice Location Address
First Line	:	1407 PATE PLAZA DR
Second Line	:
City	:	SOUTH BELOIT
State	:	IL
Zip	:	61080-1431
Country	:	US
Telephone Number	:	630-219-2002
Fax Number	:

Authorized Official
Title or Position	:	BILLER
Name	:	MR. MUBEEN SALEEM
Credential	:
Telephone Number	:	224-616-8645

Provider Enumeration Date	:	04/03/2012
Last Update Date	:	04/03/2012

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Directions to “SOUTH BELOIT OFFICE ” Practice Location

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