Provider Demographics
NPI:1861508145
Name:EL-ANSARY, MOHAMED (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:EL-ANSARY
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:PO BOX 570
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-0570
Mailing Address - Country:US
Mailing Address - Phone:847-615-2200
Mailing Address - Fax:
Practice Address - Street 1:2203 EASTLAND DR STE 7
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7924
Practice Address - Country:US
Practice Address - Phone:309-808-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092783207LP2900X
IL036-092783207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL93106Medicare PIN