Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 036061261 | IL |
N | 207PP0204X | Pediatric Emergency Physician | 036061261 | IL |
NPI | 1790717502 |
---|---|
Provider Name | Bassam Kawadry |
First Address | Naperville, IL 60540-7029 |
Second Address | Naperville, IL 60540-7029 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2006 |
Last Update Date | 22/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C42849 | (02) | IL |