Basic Information
| Provider Information | |||||||||
| NPI: | 1962588061 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AHMED | ||||||||
| FirstName: | MOHAMMED | ||||||||
| MiddleName: | SHUJAUDDIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W 22ND ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605231563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305755000 | ||||||||
| FaxNumber: | 6304915472 | ||||||||
| Practice Location | |||||||||
| Address1: | 396 REMINGTON BLVD STE 140 | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304959356 | ||||||||
| FaxNumber: | 6304959357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-113939 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | 036113939 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 400280 | 01 | IL | MEDICARE GROUP PTAN | OTHER | 036113939 | 05 | IL | MEDICAID |