Basic Information
Provider Information | |||||||||
NPI: | 1316984859 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELMAHBOUB | ||||||||
FirstName: | ASIM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 900 JORIE BLVD | ||||||||
Address2: | SUITE 186 | ||||||||
City: | OAK BROOK | ||||||||
State: | IL | ||||||||
PostalCode: | 605232213 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6309546700 | ||||||||
FaxNumber: | 6309541555 | ||||||||
Practice Location | |||||||||
Address1: | 200 HEALTH CARE DR | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 622461154 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186641230 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2006 | ||||||||
LastUpdateDate: | 05/10/2019 | ||||||||
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 | 207R00000X | 036.092411 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 036.092411 | IL | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207RA0000X | 036-092411 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Adolescent Medicine |
ID Information
ID | Type | State | Issuer | Description | L51016 | 01 | IL | MEDICARE PIN FOR GOUP #645650 | OTHER | 036092477 | 05 | IL |   | MEDICAID |