Healthcare Provider Details

I. General information

NPI: 1700119104
Provider Name (Legal Business Name): BELMONT MEDICAL & DENTAL MANAGEMENT P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5611 W BELMONT AVE
CHICAGO IL
60634-5302
US

IV. Provider business mailing address

5611 W BELMONT AVE
CHICAGO IL
60634-5302
US

V. Phone/Fax

Practice location:
  • Phone: 773-770-6400
  • Fax: 773-417-4684
Mailing address:
  • Phone: 773-770-6400
  • Fax: 773-417-4684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: AHMAD JAJEH
Title or Position: PRESIDENT
Credential:
Phone: 773-770-6400