Healthcare Provider Details

I. General information

NPI: 1669467726
Provider Name (Legal Business Name): NIZAR KHERALLAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE DEPT OF
PEORIA IL
61637-2673
US

IV. Provider business mailing address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-9844
  • Fax: 309-624-9844
Mailing address:
  • Phone: 309-624-4542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number35072648
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: