Provider Demographics
NPI:1104838788
Name:JOLIET DOCTORS CLINIC S.C.
Entity Type:Organization
Organization Name:JOLIET DOCTORS CLINIC S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WASSIM
Authorized Official - Middle Name:
Authorized Official - Last Name:EL-HARAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-730-3304
Mailing Address - Street 1:3033 W JEFFERSON ST STE 206
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5252
Mailing Address - Country:US
Mailing Address - Phone:815-730-3304
Mailing Address - Fax:815-730-3305
Practice Address - Street 1:3033 W JEFFERSON ST STE 206
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5252
Practice Address - Country:US
Practice Address - Phone:815-730-3304
Practice Address - Fax:815-730-3305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 207RE0101X
IL036102075207R00000X
IL036089327207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
001626002OtherBLUE CROSS
IL001626002ILOtherBLUE CROSS/BLUE SHIELD
IL001626002OtherBLUE CROSS
IL001626002OtherBLUE CROSS BLUE SHIELD