Provider Demographics
NPI:1508980889
Name:ILLINOIS MEDICAL CARE LTD
Entity Type:Organization
Organization Name:ILLINOIS MEDICAL CARE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHER
Authorized Official - Middle Name:
Authorized Official - Last Name:AL-KOUBAYTARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-931-8082
Mailing Address - Street 1:1721 GREENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1926
Mailing Address - Country:US
Mailing Address - Phone:773-931-8082
Mailing Address - Fax:888-847-9526
Practice Address - Street 1:5025 N PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2772
Practice Address - Country:US
Practice Address - Phone:773-931-8082
Practice Address - Fax:888-847-9526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094781207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094781Medicaid
IL036094781Medicaid