Healthcare Provider Details

I. General information

NPI: 1659592624
Provider Name (Legal Business Name): AHMED NADEEM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 NORTH OAK ST
OFALLON IL
62269
US

IV. Provider business mailing address

103 NORTH OAK ST
OFALLON IL
62269
US

V. Phone/Fax

Practice location:
  • Phone: 618-624-3368
  • Fax:
Mailing address:
  • Phone: 618-624-3368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PH0002X
TaxonomyHospice and Palliative Medicine (Emergency Medicine) Physician
License Number036117632
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-117632
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: