=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952542490
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOHAMMAD ALKHUDARI LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2009
-----------------------------------------------------
Last Update Date | 04/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1890 SILVER CROSS BLVD SUITE 330
-----------------------------------------------------
City | NEW LENOX
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60451-9508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-727-6555
-----------------------------------------------------
Fax | 815-727-1809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1890 SILVER CROSS BLVD SUITE 330
-----------------------------------------------------
City | NEW LENOX
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60451-9508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-717-6082
-----------------------------------------------------
Fax | 815-717-8693
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRES
-----------------------------------------------------
Name | DR. MOHAMMAD A. AL-KHUDARI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 815-717-6082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 3651013
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------