Healthcare Provider Details

I. General information

NPI: 1700660032
Provider Name (Legal Business Name): HAITHAM AL-DHMOUR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2023
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N 9TH ST STE 4A
SPRINGFIELD IL
62702-5310
US

IV. Provider business mailing address

PO BOX 19658
SPRINGFIELD IL
62794-9658
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-2303
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.089003
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: