1609317387 NPI number — MOHAMMED ADNAN KHALEELUDDIN D.O.

Table of content: MOHAMMED ADNAN KHALEELUDDIN D.O. (NPI 1609317387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609317387 NPI number — MOHAMMED ADNAN KHALEELUDDIN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADNAN KHALEELUDDIN
Provider First Name:
MOHAMMED
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ADNAN
Provider Other First Name:
MOHAMMED
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609317387
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19310 S HALSTED ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENWOOD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60425-1562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-300-3132
Provider Business Mailing Address Fax Number:
708-300-3149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19310 S HALSTED ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60425-1562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-300-3132
Provider Business Practice Location Address Fax Number:
708-300-3149
Provider Enumeration Date:
03/15/2017

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: 207Q00000X , with the licence number:  036152505 , 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)





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