Healthcare Provider Details

I. General information

NPI: 1881825594
Provider Name (Legal Business Name): BASIL ABU-EL-HAIJA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date: 09/21/2020
Reactivation Date: 10/23/2020

III. Provider practice location address

619 E MASON ST STE 4P57
SPRINGFIELD IL
62701-1034
US

IV. Provider business mailing address

619 E MASON ST STE 4P57
SPRINGFIELD IL
62701-1034
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-0706
  • Fax: 217-525-2535
Mailing address:
  • Phone: 217-788-0706
  • Fax: 217-525-2535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number036167582
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: