1558759738 NPI number — KIDDOS HEALTH, SC

Table of content: (NPI 1558759738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558759738 NPI number — KIDDOS HEALTH, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDDOS HEALTH, SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AXIOM CLINIC
Provider Other Organization Name Type Code:
4
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:
1558759738
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 YORKTOWN SHOPPING CTR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOMBARD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60148-5516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-520-5990
Provider Business Mailing Address Fax Number:
630-323-9044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 YORKTOWN SHOPPING CTR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOMBARD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60148-5516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-520-5990
Provider Business Practice Location Address Fax Number:
630-323-9044
Provider Enumeration Date:
12/22/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
AL-AHDAB
Authorized Official First Name:
MOHAMAD
Authorized Official Middle Name:
KHALED
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
316-440-8800

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0202X , with the licence number: 036105004 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080P0214X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0402X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 036105004 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200096860A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201276620A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200414260C , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".