Provider Demographics
NPI:1083880637
Name:MIRSHED MEDICAL CENTER S C
Entity Type:Organization
Organization Name:MIRSHED MEDICAL CENTER S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NAYEH
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:MIRSHED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-424-4048
Mailing Address - Street 1:4255 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-5041
Mailing Address - Country:US
Mailing Address - Phone:773-424-4048
Mailing Address - Fax:773-424-6463
Practice Address - Street 1:4255 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5041
Practice Address - Country:US
Practice Address - Phone:773-424-4048
Practice Address - Fax:773-424-6463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-091913207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216880Medicare PIN