Provider Demographics
NPI:1467492645
Name:REZAI, MOHAMMAD R (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:R
Last Name:REZAI
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 1:5645 W ADDISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-4403
Mailing Address - Country:US
Mailing Address - Phone:773-794-7678
Mailing Address - Fax:773-794-7694
Practice Address - Street 1:5645 W. ADDISON STREET
Practice Address - Street 2:OUR LADY OF THE RESURRECTION HOSPITAL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634
Practice Address - Country:US
Practice Address - Phone:773-282-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360616582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061685Medicaid
ILIL7584026Medicare PIN
ILC51335Medicare UPIN
ILIL7522031Medicare PIN
IL207007Medicare PIN
IL300025913Medicare PIN
IL300136830Medicare PIN