Healthcare Provider Details

I. General information

NPI: 1265434815
Provider Name (Legal Business Name): RASHID AHMED DALAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5003 N ILLINOIS ST STE 1
FAIRVIEW HEIGHTS IL
62208-3419
US

IV. Provider business mailing address

7 BEAVER CREEK CT
SAINT CHARLES MO
63303-5497
US

V. Phone/Fax

Practice location:
  • Phone: 618-239-9500
  • Fax: 618-239-9555
Mailing address:
  • Phone: 618-239-9500
  • Fax: 618-239-9555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD103192
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036090043
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: