Healthcare Provider Details

I. General information

NPI: 1316912918
Provider Name (Legal Business Name): ALI KUTOM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 08/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9115 S CICERO AVE
OAK LAWN IL
60453-1895
US

IV. Provider business mailing address

9115 S CICERO AVE
OAK LAWN IL
60453-1895
US

V. Phone/Fax

Practice location:
  • Phone: 708-229-0300
  • Fax: 708-229-0303
Mailing address:
  • Phone: 708-229-0300
  • Fax: 708-229-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036076049
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: