Healthcare Provider Details

I. General information

NPI: 1134362833
Provider Name (Legal Business Name): ALA JABER ALBAZZAZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 ROOSEVELT RD STE 140
GLEN ELLYN IL
60137-7813
US

IV. Provider business mailing address

1200 ROOSEVELT RD STE 140
GLEN ELLYN IL
60137-7813
US

V. Phone/Fax

Practice location:
  • Phone: 708-307-2103
  • Fax: 630-376-6186
Mailing address:
  • Phone: 708-307-2103
  • Fax: 630-376-6186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number036.070551
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036070551
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number036.070551
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: