=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427544113
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMEER MATARIYEH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2018
-----------------------------------------------------
Last Update Date | 07/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 S. CALIFORNIA AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-257-2158
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9028 S 55TH CT
-----------------------------------------------------
City | OAK LAWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60453-1632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-655-9572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 135.001021
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------