Basic Information
| Provider Information | |||||||||
| NPI: | 1508078239 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FATIMA JAFFER MD SC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5758 | ||||||||
| Address2: | |||||||||
| City: | VILLA PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601815308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307893133 | ||||||||
| FaxNumber: | 6307893379 | ||||||||
| Practice Location | |||||||||
| Address1: | PHYSICIANS PAVILION SUITE 101 | ||||||||
| Address2: | 24 EAST JOLIET STREET | ||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198652141 | ||||||||
| FaxNumber: | 2198642644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JAFFER | ||||||||
| AuthorizedOfficialFirstName: | FATIMA | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6307893133 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01044403A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000353010 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER |