Basic Information
| Provider Information | |||||||||
| NPI: | 1518126648 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELZOOBI PEDIATRICS LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3214 N ILLINOIS ST | ||||||||
| Address2: | |||||||||
| City: | SWANSEA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622262330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182330742 | ||||||||
| FaxNumber: | 6182339784 | ||||||||
| Practice Location | |||||||||
| Address1: | 3214 N ILLINOIS ST | ||||||||
| Address2: | |||||||||
| City: | SWANSEA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622262330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182330742 | ||||||||
| FaxNumber: | 6182339784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2008 | ||||||||
| LastUpdateDate: | 04/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | ELZOOBI | ||||||||
| AuthorizedOfficialFirstName: | KHALDOUN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6182330742 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036090591 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 112518 | 01 | BCBS OF MO | OTHER | 036090591 | 05 | IL | MEDICAID | 08222610 | 01 | BCBS OF IL | OTHER |