Basic Information
| Provider Information | |||||||||
| NPI: | 1851398218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FIDAI | ||||||||
| FirstName: | GULZAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1710 N RANDALL RD | ||||||||
| Address2: | 380 | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477419800 | ||||||||
| FaxNumber: | 8477413058 | ||||||||
| Practice Location | |||||||||
| Address1: | 1710 N RANDALL RD | ||||||||
| Address2: | 380 | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477419800 | ||||||||
| FaxNumber: | 8477413058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 036085843 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 531 | WI | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 036085843 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036085843 | 05 | IL | MEDICAID |