1912237017 NPI number — TAREK KUDAIMI MD, LLC

Table of content: (NPI 1912237017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912237017 NPI number — TAREK KUDAIMI MD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAREK KUDAIMI MD, LLC
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:
1912237017
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 MACARTHUR BLVD
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
MUNSTER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46321-2915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-836-1310
Provider Business Mailing Address Fax Number:
219-836-0617

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 MACARTHUR BLVD
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
MUNSTER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46321-2915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-836-1310
Provider Business Practice Location Address Fax Number:
219-836-0617
Provider Enumeration Date:
01/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KUDAIMI
Authorized Official First Name:
TAREK
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER MANAGER
Authorized Official Telephone Number:
219-836-1310

Provider Taxonomy Codes

  • Taxonomy code: 207RR0500X , with the licence number:  01044239 , 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: 90000885 . This is a "BLUE CROSS BLUE SHIELD ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 200191040B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3200450 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 110182794 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000095728 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 237151 . This is a "WELLCARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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