Healthcare Provider Details

I. General information

NPI: 1831191584
Provider Name (Legal Business Name): ABDULLAH ALTAYEH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 03/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 N ROCKTON AVE ROCKFORD HEALTH PHYSICIANS
ROCKFORD IL
61103-3619
US

IV. Provider business mailing address

2350 N ROCKTON AVE ROCKFORD HEALTH PHYSICIANS
ROCKFORD IL
61103-3619
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-2000
  • Fax:
Mailing address:
  • Phone: 815-971-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-112478
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number52143
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036112478
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036112478
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number104298
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22594
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: