Healthcare Provider Details

I. General information

NPI: 1023700192
Provider Name (Legal Business Name): ALI AL DAILATY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date: 12/28/2023
Reactivation Date: 04/23/2024

III. Provider practice location address

2160 S 1ST AVE LOYOLA UNIVERSITY MEDICAL CENTER
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

2160 S 1ST AVE BLDG 3100 LOYOLA UNIVERSITY GRADUATE MEDICAL EDUCATION
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 888-584-7888
  • Fax:
Mailing address:
  • Phone: 708-216-4533
  • Fax: 708-216-5446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036.180748
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: