Basic Information
| Provider Information | |||||||||
| NPI: | 1972641702 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMRAN NISAR MD LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 967 | ||||||||
| Address2: | |||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604770967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085326029 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 BIESTERFIELD RD | ||||||||
| Address2: | SUITE 510 | ||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600073311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479813660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 07/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | NISAR | ||||||||
| AuthorizedOfficialFirstName: | IMRAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7085326029 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 036091258 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 02232933 | 01 | IL | BCBSOFIL | OTHER | 036091258 | 05 | IL | MEDICAID |