Basic Information
| Provider Information | |||||||||
| NPI: | 1366937575 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FELLER | ||||||||
| FirstName: | NIDA | ||||||||
| MiddleName: | NAEEM KHAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KHAN | ||||||||
| OtherFirstName: | NIDA | ||||||||
| OtherMiddleName: | NAEEM | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 19679 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175453518 | ||||||||
| FaxNumber: | 2175452711 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 N 1ST ST STE D220 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627023757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175453518 | ||||||||
| FaxNumber: | 2175452711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2018 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 125073370 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.