1811004542 NPI number — AMJAD MOHAMMED FAHEEM M.D.

Table of content: AMJAD MOHAMMED FAHEEM M.D. (NPI 1811004542)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811004542 NPI number — AMJAD MOHAMMED FAHEEM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAHEEM
Provider First Name:
AMJAD
Provider Middle Name:
MOHAMMED
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FAHEEMUDDIN
Provider Other First Name:
AMJAD
Provider Other Middle Name:
MOHAMMED
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1811004542
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 W LINCOLN TRAIL BLVD
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
RADCLIFF
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40160-2671
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-769-0892
Provider Business Mailing Address Fax Number:
270-769-1857

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
914 N DIXIE AVE
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-2520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-769-0892
Provider Business Practice Location Address Fax Number:
270-769-1857
Provider Enumeration Date:
08/25/2006

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: 207R00000X , with the licence number:  25792 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1055555 . This is a "ELIZABETHTOWN PROV #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1055557 . This is a "RADCLIFF PP PROV #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 108814 . This is a "BLACK LUNG PROV #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 4359912 . This is a "AETNA PROVIDER #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 65937476 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000041595 . This is a "ANTHEM PROVIDER #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 65937468 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00000041594 . This is a "RC ANTHEM PROV #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1055554 . This is a "HVILLE PP OFFICE #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1055553 . This is a "RCLIFF PP OFFICE #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1055556 . This is a "HODGENVILLE PROV #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64257926 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65937492 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000041593 . This is a "HV ANTHEM PROV #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1055519 . This is a "ETOWN OFFICE PP #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1354160 . This is a "MAIL HANDLERS ET #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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