Healthcare Provider Details

I. General information

NPI: 1649851924
Provider Name (Legal Business Name): CASEM BALLOUK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2021
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7531 S STONY ISLAND AVE STE 164
CHICAGO IL
60649-3954
US

IV. Provider business mailing address

3990 JOHN R ST
DETROIT MI
48201-2018
US

V. Phone/Fax

Practice location:
  • Phone: 619-333-0214
  • Fax:
Mailing address:
  • Phone: 313-745-8040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301510121
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: