Provider Demographics
NPI:1457864407
Name:NORTHWEST MEDICAL AND URGENT CARE CENTER AT YALE AND 95TH LTD
Entity Type:Organization
Organization Name:NORTHWEST MEDICAL AND URGENT CARE CENTER AT YALE AND 95TH LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAMIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-468-2110
Mailing Address - Street 1:5352 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2316
Mailing Address - Country:US
Mailing Address - Phone:773-353-5047
Mailing Address - Fax:773-353-2406
Practice Address - Street 1:237 W 95TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-1321
Practice Address - Country:US
Practice Address - Phone:773-468-2110
Practice Address - Fax:773-468-2109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-13
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112029Medicaid