=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245428374
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALOS HEIGHTS MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2007
-----------------------------------------------------
Last Update Date | 10/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7530 W COLLEGE DR SUITE C
-----------------------------------------------------
City | PALOS HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60463-1196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-361-0911
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7530 W COLLEGE DR SUITE C
-----------------------------------------------------
City | PALOS HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60463-1196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-361-0911
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. SHAKIR MOIDUDDIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 708-361-0911
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036052775
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------