Provider Demographics
NPI:1518126648
Name:ELZOOBI PEDIATRICS LTD
Entity Type:Organization
Organization Name:ELZOOBI PEDIATRICS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALDOUN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELZOOBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-233-0742
Mailing Address - Street 1:3214 N ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2330
Mailing Address - Country:US
Mailing Address - Phone:618-233-0742
Mailing Address - Fax:618-233-9784
Practice Address - Street 1:3214 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2330
Practice Address - Country:US
Practice Address - Phone:618-233-0742
Practice Address - Fax:618-233-9784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090591208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
112518OtherBCBS OF MO
IL036090591Medicaid
08222610OtherBCBS OF IL
08222610OtherBCBS OF IL