Healthcare Provider Details

I. General information

NPI: 1245487610
Provider Name (Legal Business Name): MOHAMMED KHAIRY ATIEH D.O., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE BUILDING 110
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

2160 S 1ST AVE BUILDING 110
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-9000
  • Fax:
Mailing address:
  • Phone: 708-216-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number036123429
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: