Basic Information
Provider Information | |||||||||
NPI: | 1912330200 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NASEERULLAH | ||||||||
FirstName: | FAHAD | ||||||||
MiddleName: | SYED | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 GOOD SAMARITAN WAY | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | IL | ||||||||
PostalCode: | 628642402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6188992497 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 16811 SOUTHWEST FWY STE 300 | ||||||||
Address2: |   | ||||||||
City: | SUGAR LAND | ||||||||
State: | TX | ||||||||
PostalCode: | 774794728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6188992497 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2013 | ||||||||
LastUpdateDate: | 10/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 036140593 | IL | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | S5027 | TX | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | S5027 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.