Healthcare Provider Details

I. General information

NPI: 1982192563
Provider Name (Legal Business Name): AHMAD SHOUBAKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2018
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SILVER CROSS BLVD
NEW LENOX IL
60451-9509
US

IV. Provider business mailing address

1900 SILVER CROSS BLVD
NEW LENOX IL
60451-9509
US

V. Phone/Fax

Practice location:
  • Phone: 815-300-7910
  • Fax:
Mailing address:
  • Phone: 815-300-7910
  • Fax:

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 Code207L00000X
TaxonomyAnesthesiology Physician
License Number036159392
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: