Basic Information
| Provider Information | |||||||||
| NPI: | 1760776173 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QAYYUM | ||||||||
| FirstName: | IMAD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12251 S 80TH AVE STE 1630 | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089235173 | ||||||||
| FaxNumber: | 7089235018 | ||||||||
| Practice Location | |||||||||
| Address1: | 12255 S 80TH AVE | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089234400 | ||||||||
| FaxNumber: | 7089234421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2011 | ||||||||
| LastUpdateDate: | 01/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036.143807 | IL | N | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | 036.143807 | IL | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036143807 | 05 | IL | MEDICAID |