Basic Information
| Provider Information | |||||||||
| NPI: | 1538254693 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAIDER MEDICAL GROUP, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2036 | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600392036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157880468 | ||||||||
| FaxNumber: | 8157880489 | ||||||||
| Practice Location | |||||||||
| Address1: | 5911 NORTHWEST HWY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600148065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157880468 | ||||||||
| FaxNumber: | 8157880489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 12/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | HAIDER | ||||||||
| AuthorizedOfficialFirstName: | SYED | ||||||||
| AuthorizedOfficialMiddleName: | WASEEM | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8157880468 | ||||||||
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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 | 036100063 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036100063 | 05 | IL | MEDICAID |