Basic Information
| Provider Information | |||||||||
| NPI: | 1184989915 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AL-SHRAIDEH | ||||||||
| FirstName: | YOUSEF | ||||||||
| MiddleName: | SADEQ | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602658 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
| FaxNumber: | 3367166637 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 MAIN ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616062036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093080920 | ||||||||
| FaxNumber: | 3093080930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2012 | ||||||||
| LastUpdateDate: | 03/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2012-0604 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 208800000X | 2012-0904 | NC | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 036136798 | IL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 5921030 | 05 | NC | MEDICAID | 036136798 | 05 | IL | MEDICAID |