Provider Demographics
NPI:1760416713
Name:AL-KHALED, NOURI (MD)
Entity Type:Individual
Prefix:DR
First Name:NOURI
Middle Name:
Last Name:AL-KHALED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3545 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2135
Mailing Address - Country:US
Mailing Address - Phone:708-346-5562
Mailing Address - Fax:708-346-2059
Practice Address - Street 1:3545 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2135
Practice Address - Country:US
Practice Address - Phone:708-346-5562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-096798207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036096798Medicaid
ILIL4014003OtherMEDICARE PTAN#
0001619074OtherGROUP BC/BS
ILIL4013003OtherMEDICARE PTAN#
685583OtherGROUP MEDICARE#
IL161991361OtherGROUP NPI#
685583OtherGROUP MEDICARE#
ILG23771Medicare UPIN
ILIL4013003OtherMEDICARE PTAN#