Healthcare Provider Details

I. General information

NPI: 1275768087
Provider Name (Legal Business Name): RANA ABDUL-KHALEK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2009
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 PRAIRIE ROSE DR
ROSCOE IL
61073-7792
US

IV. Provider business mailing address

39 KENT RD SUITE 1
TIFTON GA
31794-1698
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-2000
  • Fax: 815-971-9070
Mailing address:
  • Phone: 229-391-4130
  • Fax: 229-391-4138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number072447
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036125328
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: