Healthcare Provider Details

I. General information

NPI: 1679774384
Provider Name (Legal Business Name): NADA MEMON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SAINT ANTHONYS WAY STE 305
ALTON IL
62002-4569
US

IV. Provider business mailing address

2 SAINT ANTHONYS WAY STE 305
ALTON IL
62002-4569
US

V. Phone/Fax

Practice location:
  • Phone: 618-474-6277
  • Fax: 618-474-6792
Mailing address:
  • Phone: 618-474-6277
  • Fax: 618-474-6792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036172957
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number036172957
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number33317
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: