Provider Demographics
NPI:1215446034
Name:KHALIFEH, MOHAMAD Y
Entity type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:Y
Last Name:KHALIFEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10322 S HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-2036
Mailing Address - Country:US
Mailing Address - Phone:708-576-8881
Mailing Address - Fax:708-529-7078
Practice Address - Street 1:10322 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-2036
Practice Address - Country:US
Practice Address - Phone:708-576-8881
Practice Address - Fax:708-529-7078
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D2134131291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory