Provider Demographics
NPI:1558387621
Name:MUSA, NUSRAT (MD)
Entity Type:Individual
Prefix:
First Name:NUSRAT
Middle Name:
Last Name:MUSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13618 S MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-9331
Mailing Address - Country:US
Mailing Address - Phone:708-636-8575
Mailing Address - Fax:708-636-8576
Practice Address - Street 1:3830 W 95TH ST
Practice Address - Street 2:SUITE 108
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2004
Practice Address - Country:US
Practice Address - Phone:708-636-8575
Practice Address - Fax:708-636-8576
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03659683207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE19306Medicare UPIN
IL269740Medicare ID - Type Unspecified