Provider Demographics
NPI:1083751150
Name:BASEL AL-ASWAD M D S C
Entity Type:Organization
Organization Name:BASEL AL-ASWAD M D S C
Other - Org Name:EVERGREEN ORTHOPEDICS SC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BASEL
Authorized Official - Middle Name:I
Authorized Official - Last Name:AL-ASWAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-499-4844
Mailing Address - Street 1:2850 W 95TH ST
Mailing Address - Street 2:SUITE 406
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2790
Mailing Address - Country:US
Mailing Address - Phone:708-499-4844
Mailing Address - Fax:708-499-0731
Practice Address - Street 1:2850 W 95TH ST
Practice Address - Street 2:SUITE 406
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2790
Practice Address - Country:US
Practice Address - Phone:708-499-4844
Practice Address - Fax:708-499-0731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048539207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048539OtherLICENSE NUMBER
IL31602972OtherBCBS PROVIDER #
ILCG7199OtherMEDICARE ID-RAILROAD
ILCG7199OtherMEDICARE ID-RAILROAD
IL=========OtherTAX ID
IL31602972OtherBCBS PROVIDER #
IL036048539OtherLICENSE NUMBER