Basic Information
Provider Information | |||||||||
NPI: | 1235436288 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BASHIR | ||||||||
FirstName: | AHMAD | ||||||||
MiddleName: | SAYAM | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12251 S 80TH AVE STE 202 | ||||||||
Address2: |   | ||||||||
City: | PALOS HEIGHTS | ||||||||
State: | IL | ||||||||
PostalCode: | 604631290 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7089237878 | ||||||||
FaxNumber: | 7089237888 | ||||||||
Practice Location | |||||||||
Address1: | 12255 S 80TH AVE | ||||||||
Address2: |   | ||||||||
City: | PALOS HEIGHTS | ||||||||
State: | IL | ||||||||
PostalCode: | 604631270 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7089237878 | ||||||||
FaxNumber: | 7089237888 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/26/2011 | ||||||||
LastUpdateDate: | 01/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 64067-20 | WI | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | R2832 | KY | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 036.140803 | IL | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 036.140803 | 05 | IL |   | MEDICAID |