Basic Information
| Provider Information | |||||||||
| NPI: | 1467492645 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REZAI | ||||||||
| FirstName: | MOHAMMAD | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5645 W ADDISON ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606344403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737947678 | ||||||||
| FaxNumber: | 7737947694 | ||||||||
| Practice Location | |||||||||
| Address1: | 5645 W. ADDISON STREET | ||||||||
| Address2: | OUR LADY OF THE RESURRECTION HOSPITAL | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732827000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 09/24/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 036061658 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 036061685 | 05 | IL | MEDICAID |