Provider Demographics
NPI:1730349028
Name:BOUMENDJEL, REDOUANE (MD)
Entity type:Individual
Prefix:DR
First Name:REDOUANE
Middle Name:
Last Name:BOUMENDJEL
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 1:1775 DEMPSTER ST
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1143
Mailing Address - Country:US
Mailing Address - Phone:847-723-5549
Mailing Address - Fax:847-723-7540
Practice Address - Street 1:840 S WOOD ST
Practice Address - Street 2:SUITE 130 CSN
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-996-7250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125051840207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology