Basic Information
| Provider Information | |||||||||
| NPI: | 1134425085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSHRA | ||||||||
| FirstName: | NASSER | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 PAYSPHERE CIR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606740018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304699200 | ||||||||
| FaxNumber: | 6303710138 | ||||||||
| Practice Location | |||||||||
| Address1: | 2340 S HIGHLAND AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | LOMBARD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601487132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309322020 | ||||||||
| FaxNumber: | 7734510461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2011 | ||||||||
| LastUpdateDate: | 01/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036131561 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036131561 | 05 | IL | MEDICAID | 036131561 | 01 | IL | IL LICENSE | OTHER |