Basic Information
| Provider Information | |||||||||
| NPI: | 1912017898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAIDER | ||||||||
| FirstName: | SYED | ||||||||
| MiddleName: | WASEEM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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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: | 650 DAKOTA ST STE A | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600123744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154556000 | ||||||||
| FaxNumber: | 8153561104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036100063 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036100063 | 05 | IL | MEDICAID |