1033355631 NPI number — MAQBOOL AHMAD

Table of content: (NPI 1033355631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033355631 NPI number — MAQBOOL AHMAD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAQBOOL AHMAD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1033355631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 W DEYOUNG ST
Provider Second Line Business Mailing Address:
P.O. BOX 1178
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62959-4437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-993-5686
Provider Business Mailing Address Fax Number:
618-997-6250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 BROADWAY ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62864-2341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-993-5686
Provider Business Practice Location Address Fax Number:
618-997-6250
Provider Enumeration Date:
01/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
AHMAD
Authorized Official First Name:
MAQBOOL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
618-993-5686

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  036051996 , 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)

  • Identifier: 51524 . This is a "BCBS OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00802628 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: A03147 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com