Healthcare Provider Details

I. General information

NPI: 1417951971
Provider Name (Legal Business Name): EZZELDIN A SALEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2005
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N 8TH ST STE 4A
SPRINGFIELD IL
62701-1013
US

IV. Provider business mailing address

PO BOX 19658
SPRINGFIELD IL
62794-9658
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-6040
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-6040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number036-144396
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: