Provider Demographics
NPI:1093801052
Name:MIDWEST CLINIC PC
Entity Type:Organization
Organization Name:MIDWEST CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:ABDUL RAOOF
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-865-0918
Mailing Address - Street 1:13 W US HWY 30
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375
Mailing Address - Country:US
Mailing Address - Phone:219-865-0918
Mailing Address - Fax:219-864-8332
Practice Address - Street 1:13 W US HWY 30
Practice Address - Street 2:MIDWEST CLINIC
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375
Practice Address - Country:US
Practice Address - Phone:219-865-0918
Practice Address - Fax:219-864-8332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041447207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100356480DMedicaid
IN406870Medicare ID - Type Unspecified
IN100356480DMedicaid