Provider Demographics
NPI:1205292281
Name:MJM MEDICAL CORP
Entity type:Organization
Organization Name:MJM MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:224-412-1720
Mailing Address - Street 1:5696 HEIDI DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61109-1768
Mailing Address - Country:US
Mailing Address - Phone:224-412-1720
Mailing Address - Fax:
Practice Address - Street 1:5696 HEIDI DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-1768
Practice Address - Country:US
Practice Address - Phone:224-412-1720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-127728207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I51407Medicare UPIN