Basic Information
Provider Information | |||||||||
NPI: | 1174534564 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TABRIZ | ||||||||
FirstName: | MUHAMMAD | ||||||||
MiddleName: | SHAMSE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TABRIZ | ||||||||
OtherFirstName: | MD | ||||||||
OtherMiddleName: | SHAMSE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 777 OAKMONT LN | ||||||||
Address2: | SUITE 1600 | ||||||||
City: | WESTMONT | ||||||||
State: | IL | ||||||||
PostalCode: | 605595511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6307892550 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7804 W COLLEGE DR | ||||||||
Address2: | SUITE 1NW | ||||||||
City: | PALOS HEIGHTS | ||||||||
State: | IL | ||||||||
PostalCode: | 604631025 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7083615778 | ||||||||
FaxNumber: | 7083615631 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2006 | ||||||||
LastUpdateDate: | 12/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 036108516 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
ID | Type | State | Issuer | Description | P00060304 | 01 | IL | RAILROAD MEDICARE | OTHER | 21622441 | 01 | IL | BCBS PROVIDER ID | OTHER | 036108516 | 05 | IL |   | MEDICAID |