Healthcare Provider Details

I. General information

NPI: 1639951338
Provider Name (Legal Business Name): MADINA HOUSE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43575 MISSION BLVD # 1019
FREMONT CA
94539-5831
US

IV. Provider business mailing address

43575 MISSION BLVD # 1019
FREMONT CA
94539-5831
US

V. Phone/Fax

Practice location:
  • Phone: 510-902-7080
  • Fax:
Mailing address:
  • Phone: 510-902-7080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. AMER SYED RAHEEMULLAH
Title or Position: MEDICAL DIRECTOR/PRESIDENT
Credential: MD
Phone: 510-902-7080