Provider Demographics
NPI:1821112046
Name:MOHIN T SAMARAWEERA MD SC PLAINFIELD MEDICAL CENTER
Entity Type:Organization
Organization Name:MOHIN T SAMARAWEERA MD SC PLAINFIELD MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MOHIN
Authorized Official - Middle Name:TISSA
Authorized Official - Last Name:SAMARAWEERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-436-7303
Mailing Address - Street 1:24016 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-2232
Mailing Address - Country:US
Mailing Address - Phone:815-436-7303
Mailing Address - Fax:815-609-7980
Practice Address - Street 1:24016 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-2232
Practice Address - Country:US
Practice Address - Phone:815-436-7303
Practice Address - Fax:815-609-7980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36048836208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9900490OtherBC BS OF IL
D14209Medicare UPIN
208665Medicare PIN