1528019619 NPI number — SAJJAD H HABIB 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 1528019619 NPI number — SAJJAD H HABIB MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HABIB
Provider First Name:
SAJJAD
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1528019619
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 W 22ND ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK BROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60523-1563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-573-5000
Provider Business Mailing Address Fax Number:
630-491-5472

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7836 W JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-4165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-494-3484
Provider Business Practice Location Address Fax Number:
260-969-0188
Provider Enumeration Date:
05/13/2006

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: 207RN0300X , with the licence number:  01061182 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200805040 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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