1720182074 NPI number — MR. GULAM AE HAJAT MD

Table of content: MR. GULAM AE HAJAT MD (NPI 1720182074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720182074 NPI number — MR. GULAM AE HAJAT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAJAT
Provider First Name:
GULAM
Provider Middle Name:
AE
Provider Name Prefix Text:
MR.
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:
HAJAT
Provider Other First Name:
GULAM
Provider Other Middle Name:
AHMED
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1720182074
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28 DEER PATH TRL
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:
60527-6324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-272-4265
Provider Business Mailing Address Fax Number:
708-489-6249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11808 S PULASKI RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALSIP
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60803-1608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-489-6200
Provider Business Practice Location Address Fax Number:
708-489-6249
Provider Enumeration Date:
09/08/2006

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: 208000000X , with the licence number:  336019374 , 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: 036054708 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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