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General NPI Number Information
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NPI Number | 1780662254
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Entity Type | Individual
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Provider Name | WALID NASRI GHANTOUS M.D.
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Gender | Male
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Dates
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Enumeration Date | 01/05/2006
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Last Update Date | 09/13/2012
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Provider Practice Location Address
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Address Line | 101 S GREENLEAF ST
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City | GURNEE
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State | IL
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Zip | 60031-3369
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Country | US
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Telephone | 847-446-3200
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Fax | 847-446-2934
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Provider Business Mailing Address
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Address Line | 343 RIDGE RD
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City | WILMETTE
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State | IL
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Zip | 60091-3251
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Country | US
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Telephone | 847-446-3200
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Fax | 847-446-2934
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 036-044591
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License Number State | IL
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