Provider Demographics
NPI:1679853188
Name:LEAVITT HEALTHCARE AND DIAGNOSTIC INC
Entity Type:Organization
Organization Name:LEAVITT HEALTHCARE AND DIAGNOSTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HATEM
Authorized Official - Middle Name:A
Authorized Official - Last Name:GALAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-733-0901
Mailing Address - Street 1:2158 W GRAND AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1571
Mailing Address - Country:US
Mailing Address - Phone:312-733-0901
Mailing Address - Fax:312-733-0917
Practice Address - Street 1:2158 W GRAND AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-1571
Practice Address - Country:US
Practice Address - Phone:312-733-0901
Practice Address - Fax:312-733-0917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036046113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty