Provider Demographics
NPI:1437119450
Name:KALEEMUDDIN, MOHAMMED (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:
Last Name:KALEEMUDDIN
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 1:9951 ROCK CUT XING
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-1999
Mailing Address - Country:US
Mailing Address - Phone:815-639-8450
Mailing Address - Fax:815-639-8451
Practice Address - Street 1:9951 ROCK CUT XING
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-1999
Practice Address - Country:US
Practice Address - Phone:815-639-8450
Practice Address - Fax:815-639-8451
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043590A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL553180OtherMEDICARE GROUP NUMBER
IN000000092799OtherBCBS
IL834340OtherMEDICARE GROUP NUMBER
IN200105080Medicaid
IL553180030Medicare PIN
IL553180OtherMEDICARE GROUP NUMBER
IN131290RMedicare ID - Type UnspecifiedFIRST AVENUE LOCATION
IN200105080Medicaid
IL834340014Medicare PIN