Provider Demographics
NPI:1558759738
Name:KIDDOS HEALTH, SC
Entity Type:Organization
Organization Name:KIDDOS HEALTH, SC
Other - Org Name:AXIOM CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMAD
Authorized Official - Middle Name:KHALED
Authorized Official - Last Name:AL-AHDAB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-440-8800
Mailing Address - Street 1:3 YORKTOWN SHOPPING CTR
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-5516
Mailing Address - Country:US
Mailing Address - Phone:630-520-5990
Mailing Address - Fax:630-323-9044
Practice Address - Street 1:3 YORKTOWN SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-5516
Practice Address - Country:US
Practice Address - Phone:630-520-5990
Practice Address - Fax:630-323-9044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-22
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X, 2080P0214X, 2084N0402X, 261QU0200X, 332B00000X
IL0361050042080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105004Medicaid
OK200096860AMedicaid
IN201276620AMedicaid
KS200414260CMedicaid