Provider Demographics
NPI:1487756474
Name:MANSUR, BAHIR A (MD)
Entity type:Individual
Prefix:MR
First Name:BAHIR
Middle Name:A
Last Name:MANSUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7318 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-3100
Mailing Address - Country:US
Mailing Address - Phone:708-366-1871
Mailing Address - Fax:708-366-4519
Practice Address - Street 1:7318 MADISON ST
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-3100
Practice Address - Country:US
Practice Address - Phone:708-366-1871
Practice Address - Fax:708-366-4519
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-065718207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-065718Medicaid
IL036-065718Medicaid