Provider Demographics
NPI:1699264622
Name:MOOSA, SAMIRALY (MD)
Entity type:Individual
Prefix:
First Name:SAMIRALY
Middle Name:
Last Name:MOOSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 N. FRANCISCO AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622
Mailing Address - Country:US
Mailing Address - Phone:773-292-8200
Mailing Address - Fax:773-278-3889
Practice Address - Street 1:1044 N. FRANCISCO AVENUE ATTN. GME OFFICE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622
Practice Address - Country:US
Practice Address - Phone:773-360-6346
Practice Address - Fax:773-292-5954
Is Sole Proprietor?:No
Enumeration Date:2018-05-04
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036153598207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program