Basic Information
Provider Information | |||||||||
NPI: | 1508857061 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAMID | ||||||||
FirstName: | IMTIAZ | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17901 GOVERNORS HWY | ||||||||
Address2: | SUITE 101 | ||||||||
City: | HOMEWOOD | ||||||||
State: | IL | ||||||||
PostalCode: | 604301144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7087990180 | ||||||||
FaxNumber: | 7087993839 | ||||||||
Practice Location | |||||||||
Address1: | 17901 GOVERNORS HWY | ||||||||
Address2: | SUITE 101 | ||||||||
City: | HOMEWOOD | ||||||||
State: | IL | ||||||||
PostalCode: | 604301144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7087990180 | ||||||||
FaxNumber: | 7087993839 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/03/2005 | ||||||||
LastUpdateDate: | 04/02/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X |   | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 21624320 | 01 | IL | BCBS OF IL | OTHER | CB1134 | 01 | IL | RR MEDICARE | OTHER |