Provider Demographics
NPI:1831634880
Name:ELBUSHRA, SOMIA
Entity type:Individual
Prefix:
First Name:SOMIA
Middle Name:
Last Name:ELBUSHRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4909 N MARMORA AVE
Mailing Address - Street 2:UNIT # 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1991
Mailing Address - Country:US
Mailing Address - Phone:312-874-9586
Mailing Address - Fax:
Practice Address - Street 1:4909 N MARMORA AVE
Practice Address - Street 2:UNIT # 2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-1991
Practice Address - Country:US
Practice Address - Phone:312-874-9586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-30
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)