Provider Demographics
NPI:1023224987
Name:OWEIMRIN, KHALED P (PT)
Entity type:Individual
Prefix:MR
First Name:KHALED
Middle Name:P
Last Name:OWEIMRIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E NORTHWEST HWY STE 103
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-3457
Mailing Address - Country:US
Mailing Address - Phone:847-227-8400
Mailing Address - Fax:847-239-7686
Practice Address - Street 1:8019 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-3611
Practice Address - Country:US
Practice Address - Phone:773-490-0151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-010227225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216447OtherMEDICARE PTAN
IL216447OtherMEDICARE PTAN