Basic Information
| Provider Information | |||||||||
| NPI: | 1700819562 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INFECTIOUS DISEASE CONSULTANTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1805 KIMBERLY LAKE DR | ||||||||
| Address2: | |||||||||
| City: | SWANSEA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622262061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183559970 | ||||||||
| FaxNumber: | 6183559972 | ||||||||
| Practice Location | |||||||||
| Address1: | 4550 MEMORIAL DR STE 360 | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182225999 | ||||||||
| FaxNumber: | 6182399555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 05/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | BADAHMAN | ||||||||
| AuthorizedOfficialFirstName: | OMER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6182225999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 036102100 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 036102100 | 05 | IL | MEDICAID |