Basic Information
| Provider Information | |||||||||
| NPI: | 1295896173 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMARAWEERA | ||||||||
| FirstName: | MOHIN | ||||||||
| MiddleName: | TISSA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24016 W MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | PLAINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154367303 | ||||||||
| FaxNumber: | 8156097980 | ||||||||
| Practice Location | |||||||||
| Address1: | 24016 W MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | PLAINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154367303 | ||||||||
| FaxNumber: | 8156097980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 12/22/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 36048836 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03L048836 | 05 | IL | MEDICAID | 9900490 | 01 | IL | BC BS | OTHER |