Healthcare Provider Details

I. General information

NPI: 1215912977
Provider Name (Legal Business Name): ARIF HABIB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 MADISON AVE STE 404
GRANITE CITY IL
62040
US

IV. Provider business mailing address

2120 MADISON AVE STE 404
GRANITE CITY IL
62040
US

V. Phone/Fax

Practice location:
  • Phone: 618-876-7515
  • Fax: 618-876-7596
Mailing address:
  • Phone: 618-876-7515
  • Fax: 618-876-7596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number336.062826
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number119759
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036101209
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: