Healthcare Provider Details

I. General information

NPI: 1124889688
Provider Name (Legal Business Name): USAMAH TABANI DO, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 BALLARD RD
PARK RIDGE IL
60068-1005
US

IV. Provider business mailing address

11 HILLS BEACH RD
BIDDEFORD ME
04005-9599
US

V. Phone/Fax

Practice location:
  • Phone: 847-723-2210
  • Fax:
Mailing address:
  • Phone: 207-283-0171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.085534
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: