Basic Information
Provider Information | |||||||||
NPI: | 1467518118 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GHALI | ||||||||
FirstName: | WAEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2650 RIDGE AVE | ||||||||
Address2: |   | ||||||||
City: | EVANSTON | ||||||||
State: | IL | ||||||||
PostalCode: | 602011718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475701010 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2650 RIDGE AVE | ||||||||
Address2: |   | ||||||||
City: | EVANSTON | ||||||||
State: | IL | ||||||||
PostalCode: | 602011718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475701010 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2006 | ||||||||
LastUpdateDate: | 05/02/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 041702 | CT | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | BG8434413 | 01 | IL | FED DEA REGISTRATION | OTHER | 041702 | 01 | CT | CT PHYSICIAN LICENSE | OTHER | 33840 | 01 | CT | CT CSR | OTHER | 001417022 | 05 | IL |   | MEDICAID |