1295760411 NPI number — DR. HABEEBA MOIDUDDIN MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295760411 NPI number — DR. HABEEBA MOIDUDDIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOIDUDDIN
Provider First Name:
HABEEBA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295760411
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 CIRCLE RIDGE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURR RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-202-2584
Provider Business Mailing Address Fax Number:
708-202-2163

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
EDWARD HINES VA MEDICAL CENTER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HINES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-202-2584
Provider Business Practice Location Address Fax Number:
708-202-2163
Provider Enumeration Date:
07/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0300X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)