Provider Demographics
NPI:1306904131
Name:KHATER, RUSSELL I (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:I
Last Name:KHATER
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 1:1106 N LARKIN AVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-3455
Mailing Address - Country:US
Mailing Address - Phone:815-725-6188
Mailing Address - Fax:815-741-1541
Practice Address - Street 1:1106 N LARKIN AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-3455
Practice Address - Country:US
Practice Address - Phone:815-725-6188
Practice Address - Fax:815-741-1541
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098419174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036041596Medicaid
IL036041596Medicaid
IL545240Medicare ID - Type Unspecified