Provider Demographics
NPI:1811102353
Name:MEDICAL CARE CENTER OF LAKE VILLA
Entity type:Organization
Organization Name:MEDICAL CARE CENTER OF LAKE VILLA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN AND SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:E
Authorized Official - Last Name:NASR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-356-9009
Mailing Address - Street 1:213 S MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-8551
Mailing Address - Country:US
Mailing Address - Phone:847-356-9009
Mailing Address - Fax:
Practice Address - Street 1:213 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-8551
Practice Address - Country:US
Practice Address - Phone:847-356-9009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058768207Q00000X, 207R00000X, 2083P0500X, 2083P0901X, 208600000X, 208D00000X
IL036082737207Q00000X, 207R00000X, 208D00000X
IL036047948207Q00000X, 208600000X, 208D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Single Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID #
IL634311Medicare UPIN