Basic Information
| Provider Information | |||||||||
| NPI: | 1821112046 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOHIN T SAMARAWEERA MD SC PLAINFIELD MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24016 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PLAINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605442232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154367303 | ||||||||
| FaxNumber: | 8156097980 | ||||||||
| Practice Location | |||||||||
| Address1: | 24016 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PLAINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605442232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154367303 | ||||||||
| FaxNumber: | 8156097980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 09/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | SAMARAWEERA | ||||||||
| AuthorizedOfficialFirstName: | MOHIN | ||||||||
| AuthorizedOfficialMiddleName: | TISSA | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8154367303 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 36048836 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 9900490 | 01 | IL | BC BS OF IL | OTHER |