Provider Demographics
NPI:1831191584
Name:ALTAYEH, ABDULLAH (MD)
Entity type:Individual
Prefix:DR
First Name:ABDULLAH
Middle Name:
Last Name:ALTAYEH
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 1:2350 N ROCKTON AVE
Mailing Address - Street 2:ROCKFORD HEALTH PHYSICIANS
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3619
Mailing Address - Country:US
Mailing Address - Phone:815-971-2000
Mailing Address - Fax:
Practice Address - Street 1:2350 N ROCKTON AVE
Practice Address - Street 2:ROCKFORD HEALTH PHYSICIANS
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3619
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-112478207R00000X
MN52143207R00000X
IL036112478207RP1001X, 207R00000X
MN104298207R00000X
WV22594207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
OH000000270600Medicaid
IL036-112478-1Medicaid
OH2932518Medicaid
WV4256041Medicare PIN
MNENROLLEDMedicaid
MN110012749Medicare PIN
ILK108002/357801Medicare ID - Type Unspecified