1114127800 NPI number — MISBAH UDDIN AHMED MD SC

Table of content: (NPI 1114127800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114127800 NPI number — MISBAH UDDIN AHMED MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISBAH UDDIN AHMED MD SC
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:
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:
1114127800
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 W COURT ST
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
KANKAKEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60901-3674
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-935-2525
Provider Business Mailing Address Fax Number:
815-935-1010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 W COURT ST
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
KANKAKEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60901-3664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-935-2525
Provider Business Practice Location Address Fax Number:
815-935-1010
Provider Enumeration Date:
07/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AHMED
Authorized Official First Name:
MISBAH
Authorized Official Middle Name:
UDDIN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
815-935-2525

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1306854203 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036205509 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: CG4030 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 110197518 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036098582 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1922117811 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 930068554 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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