Provider Demographics
NPI:1336670322
Name:KHAROUTA, MICHAEL Z
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:Z
Last Name:KHAROUTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 COMMERCE DR
Mailing Address - Street 2:STE 500
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8736
Mailing Address - Country:US
Mailing Address - Phone:630-205-6612
Mailing Address - Fax:847-698-0601
Practice Address - Street 1:900 W NELSON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6704
Practice Address - Country:US
Practice Address - Phone:773-296-7076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361591632085R0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036159163OtherSTATE LICENSE