Healthcare Provider Details

I. General information

NPI: 1063116978
Provider Name (Legal Business Name): KYSE OSSAMA ZORUB
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16255 HARLEM AVE
TINLEY PARK IL
60477-1615
US

IV. Provider business mailing address

14341 DEER HAVEN LN
ORLAND PARK IL
60467-8103
US

V. Phone/Fax

Practice location:
  • Phone: 708-599-5000
  • Fax: 708-599-0801
Mailing address:
  • Phone: 708-307-5098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016006181
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: