Provider Demographics
NPI:1649650961
Name:ALHALLAQ LLC
Entity type:Organization
Organization Name:ALHALLAQ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YOUSIF
Authorized Official - Middle Name:
Authorized Official - Last Name:ALHALLAQ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-259-1145
Mailing Address - Street 1:4568 DRESSLER RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2546
Mailing Address - Country:US
Mailing Address - Phone:330-259-1145
Mailing Address - Fax:330-259-1140
Practice Address - Street 1:4568 DRESSLER RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2546
Practice Address - Country:US
Practice Address - Phone:330-259-1145
Practice Address - Fax:330-259-1140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-02
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35094254207R00000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3009229Medicaid
OH1275659104OtherNPI INDIVIDUAL