Healthcare Provider Details

I. General information

NPI: 1669888327
Provider Name (Legal Business Name): THAER AHMAD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-4393
  • Fax: 708-684-1028
Mailing address:
  • Phone: 708-684-4393
  • Fax: 708-684-1028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301105787
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-142683
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: