Healthcare Provider Details

I. General information

NPI: 1548170913
Provider Name (Legal Business Name): MED SPA OF MT GREENWOOD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10301 S KEDZIE AVE UNIT A
CHICAGO IL
60655-2015
US

IV. Provider business mailing address

10301 S KEDZIE AVE UNIT A
CHICAGO IL
60655-2015
US

V. Phone/Fax

Practice location:
  • Phone: 708-374-0118
  • Fax:
Mailing address:
  • Phone: 708-374-0118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KHADER ZAHDAN
Title or Position: MANAGER
Credential: DO
Phone: 708-374-0118