Provider Demographics
NPI:1023101086
Name:PRISM MEDICAL CENTER OF IL NFP
Entity type:Organization
Organization Name:PRISM MEDICAL CENTER OF IL NFP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:SAUDYE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-262-1300
Mailing Address - Street 1:6346 N TALMAN AVE
Mailing Address - Street 2:STE # 102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-1898
Mailing Address - Country:US
Mailing Address - Phone:773-262-1300
Mailing Address - Fax:773-262-1184
Practice Address - Street 1:6346 N TALMAN AVE
Practice Address - Street 2:STE # 102
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-1898
Practice Address - Country:US
Practice Address - Phone:773-262-1300
Practice Address - Fax:773-262-1184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X, 207R00000X, 207RI0011X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01633175OtherBCBS
IL210965Medicare ID - Type Unspecified