Provider Demographics
NPI:1932635083
Name:SSD MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SSD MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAZIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAUDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-230-9808
Mailing Address - Street 1:12151 REGENCY PKWY STE 12165
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-7644
Mailing Address - Country:US
Mailing Address - Phone:847-230-9808
Mailing Address - Fax:847-984-1915
Practice Address - Street 1:12151 REGENCY PKWY STE 12165
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-7644
Practice Address - Country:US
Practice Address - Phone:847-230-9808
Practice Address - Fax:847-984-1915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336072732302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111912Medicaid
IL036111912Medicaid