Provider Demographics
NPI:1144216243
Name:MOHIUDDIN, SYED M (MD)
Entity Type:Individual
Prefix:
First Name:SYED
Middle Name:M
Last Name:MOHIUDDIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 N PERRYVILLE RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6225
Mailing Address - Country:US
Mailing Address - Phone:815-227-9900
Mailing Address - Fax:815-227-9805
Practice Address - Street 1:695 N PERRYVILLE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6225
Practice Address - Country:US
Practice Address - Phone:815-227-9900
Practice Address - Fax:815-227-9805
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055808207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL553180OtherMEDICARE GROUP PTAN
ILCC5050Medicare ID - Type UnspecifiedRR MEDICARE #
G68669Medicare UPIN
ILK12579Medicare ID - Type Unspecified
IL553180022Medicare PIN
IL553180OtherMEDICARE GROUP PTAN
ILP00302313Medicare ID - Type UnspecifiedRR INDIVIDUAL #