Healthcare Provider Details

I. General information

NPI: 1174556583
Provider Name (Legal Business Name): HATIM A MAHMOOD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S 3RD ST STE 300
BELLEVILLE IL
62220-1952
US

IV. Provider business mailing address

180 S 3RD ST STE 300
BELLEVILLE IL
62220-1952
US

V. Phone/Fax

Practice location:
  • Phone: 618-213-7933
  • Fax: 618-213-7934
Mailing address:
  • Phone: 618-213-7933
  • Fax: 618-213-7934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036096289
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number036096289
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036096289
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: