Provider Demographics
NPI:1336111681
Name:ELTAYEB, OSAMA M (MD)
Entity Type:Individual
Prefix:
First Name:OSAMA
Middle Name:M
Last Name:ELTAYEB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:225 E CHICAGO AVENUE, BOX 22
Mailing Address - Street 2:ANN & ROBERT H. LURIE CHILDRENS HOSPITAL OF CHICAGO
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-4240
Mailing Address - Fax:312-227-9643
Practice Address - Street 1:225 E CHICAGO AVENUE, BOX 22
Practice Address - Street 2:ANN & ROBERT H. LURIE CHILDRENS HOSPITAL OF CHICAGO
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-4240
Practice Address - Fax:312-227-9643
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036128558208G00000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036128558OtherSTATE LICENSE
GA897905179ABMedicaid
I45882Medicare UPIN
GA02BDHZJMedicare ID - Type Unspecified