Provider Demographics
NPI:1710009204
Name:ST MARY INTERNAL MEDICINE ASSOCIATES S C
Entity Type:Organization
Organization Name:ST MARY INTERNAL MEDICINE ASSOCIATES S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHRAF
Authorized Official - Middle Name:ASSAAD
Authorized Official - Last Name:ISKANDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-609-9480
Mailing Address - Street 1:2320 S ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-7756
Mailing Address - Country:US
Mailing Address - Phone:815-609-9480
Mailing Address - Fax:815-609-9482
Practice Address - Street 1:2320 S ROUTE 59
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60586-7756
Practice Address - Country:US
Practice Address - Phone:815-609-9480
Practice Address - Fax:815-609-9482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094077261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094077Medicaid
IL036094077Medicaid
ILG81406Medicare UPIN