Basic Information
Provider Information | |||||||||
NPI: | 1336125327 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ATASSI | ||||||||
FirstName: | WADAH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 120 W 22ND ST STE 200 | ||||||||
Address2: |   | ||||||||
City: | OAK BROOK | ||||||||
State: | IL | ||||||||
PostalCode: | 605231563 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6305755000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2701 W 68TH STREET | ||||||||
Address2: | PROFESSIONAL PAVILION 4 SOUTH | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606291813 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7737354884 | ||||||||
FaxNumber: | 7737352625 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2005 | ||||||||
LastUpdateDate: | 12/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 036081178 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 01621679 | 01 | IL | BCBS OF IL | OTHER | 036081178 | 05 | IL |   | MEDICAID | 01615184 | 01 | IL | BCBS | OTHER |