Basic Information
| Provider Information | |||||||||
| NPI: | 1780034926 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHARIF | ||||||||
| FirstName: | AHMED | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3988 | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629023988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185490721 | ||||||||
| FaxNumber: | 6185290479 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 W JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185366621 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2016 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 125068327 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036149433 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 036149433 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 214881 | 01 | IL | MULTI SPECIALTY GROUP PTAN | OTHER |