Healthcare Provider Details

I. General information

NPI: 1073138277
Provider Name (Legal Business Name): ABRAHAM SAMIR KHEIREDDIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 EXECUTIVE DR STE 250
WESTMONT IL
60559-6137
US

IV. Provider business mailing address

250 S NORTHWEST HWY STE 200
PARK RIDGE IL
60068-4252
US

V. Phone/Fax

Practice location:
  • Phone: 630-323-6116
  • Fax: 630-323-5610
Mailing address:
  • Phone: 847-324-3976
  • Fax: 847-929-1154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085009053
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: