Provider Demographics
NPI:1629266341
Name:PURI, MOHAMMAD MUNEEB (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:MUNEEB
Last Name:PURI
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 1:210 S DESPLAINES ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-5500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2315 E 93RD ST STE 337
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3948
Practice Address - Country:US
Practice Address - Phone:708-952-3040
Practice Address - Fax:708-952-3043
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036134881207R00000X
NY003612208M00000X
MDD74204208M00000X
IL036.134881207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD230400700Medicaid
NY03239136Medicaid
MDP01122421Medicare PIN
MD230400700Medicaid
NYJ400056965Medicare PIN
NYPENDINGMedicare PIN
MD242153Y1PMedicare PIN