Basic Information
| Provider Information | |||||||||
| NPI: | 1144203753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KABBANI | ||||||||
| FirstName: | HAIDAR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2160 S 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601533328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082169000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2160 S 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082169000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 06/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35530 | IA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2084N0400X | 35.096508 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084P0804X | 35.096508 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084N0402X | 036141882 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0444802 | 05 | IA | MEDICAID |