Healthcare Provider Details

I. General information

NPI: 1396939500
Provider Name (Legal Business Name): GHIATH AL KASSAR M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E BOUGHTON RD
BOLINGBROOK IL
60440-2181
US

IV. Provider business mailing address

516 E BOUGHTON RD
BOLINGBROOK IL
60440-2181
US

V. Phone/Fax

Practice location:
  • Phone: 630-456-0708
  • Fax:
Mailing address:
  • Phone: 630-456-0708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number42925
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: