Basic Information
| Provider Information | |||||||||
| NPI: | 1962528356 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAHDI | ||||||||
| FirstName: | MIRZA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 925 SHERWOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAKE BLUFF | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600442203 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 836 W WELLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739751600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
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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 | 207L00000X | 036066607 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 01081427A | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 036066607 | 05 | IL | MEDICAID |