1134148091 NPI number — DR. MAHMOUD MAHAFZAH MD, PH.D

Table of content: DR. MAHMOUD MAHAFZAH MD, PH.D (NPI 1134148091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134148091 NPI number — DR. MAHMOUD MAHAFZAH MD, PH.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAHAFZAH
Provider First Name:
MAHMOUD
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, PH.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134148091
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
62647 COLLECTION CENTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60693-0626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-599-9385
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10604 SOUTHWEST HWY STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO RIDGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60415-2717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-424-9710
Provider Business Practice Location Address Fax Number:
708-671-9282
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  036091528 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036091528 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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