Provider Demographics
NPI:1316946700
Name:EL KHADRA, MAAN SAMI (MD)
Entity type:Individual
Prefix:
First Name:MAAN
Middle Name:SAMI
Last Name:EL KHADRA
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 1:1901 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3714
Mailing Address - Country:US
Mailing Address - Phone:312-864-3036
Mailing Address - Fax:312-864-9349
Practice Address - Street 1:1901 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3714
Practice Address - Country:US
Practice Address - Phone:312-864-3036
Practice Address - Fax:312-864-9349
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073394207RC0000X, 207RI0011X
IL36-073394207RC0000X, 2085R0204X
MN66630207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01621175OtherBCBS
IL630001349OtherRR MIA
IL036073394Medicaid
IL630001349OtherRR MIA
F52517Medicare UPIN