Healthcare Provider Details

I. General information

NPI: 1710037742
Provider Name (Legal Business Name): RAID ABDULLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PKWY 770 JONES
CHICAGO IL
60612-3833
US

IV. Provider business mailing address

1653 W CONGRESS PKWY 770 JONES
CHICAGO IL
60612-3833
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6800
  • Fax: 312-942-6801
Mailing address:
  • Phone: 312-942-6800
  • Fax: 312-942-6801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-085177
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number036085177
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: