Provider Demographics
NPI:1376751982
Name:WALID N. GHANTOUS MD LTD
Entity Type:Organization
Organization Name:WALID N. GHANTOUS MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALID
Authorized Official - Middle Name:
Authorized Official - Last Name:GHANTOUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-855-9152
Mailing Address - Street 1:PO BOX 557
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-0557
Mailing Address - Country:US
Mailing Address - Phone:847-446-3200
Mailing Address - Fax:847-855-5215
Practice Address - Street 1:1445 N HUNT CLUB RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-2603
Practice Address - Country:US
Practice Address - Phone:847-855-9152
Practice Address - Fax:847-855-5215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL461340Medicare ID - Type UnspecifiedPROVIDER NUMBER