Provider Demographics
NPI:1760430557
Name:MAKDAH, SALEM JAD (MD)
Entity Type:Individual
Prefix:
First Name:SALEM
Middle Name:JAD
Last Name:MAKDAH
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 1:12251 S 80TH AVE STE 1630
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1256
Mailing Address - Country:US
Mailing Address - Phone:708-923-5173
Mailing Address - Fax:708-923-5018
Practice Address - Street 1:15300 WEST AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4600
Practice Address - Country:US
Practice Address - Phone:708-923-7874
Practice Address - Fax:708-923-7876
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-01-03
Deactivation Date:2018-08-27
Deactivation Code:
Reactivation Date:2018-09-19
Provider Licenses
StateLicense IDTaxonomies
IL036075762207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036075762Medicaid
IL0031602823OtherBLUE CROSS BLUE SHIELD
IL036075762Medicaid
ILC44960Medicare UPIN
IL036075762Medicaid