Healthcare Provider Details

I. General information

NPI: 1164787792
Provider Name (Legal Business Name): SYED AFFAN UL HAQ HASHMI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 VOLLMER RD
OLYMPIA FIELDS IL
60461-1179
US

IV. Provider business mailing address

PO BOX 3877
JOLIET IL
60434-3877
US

V. Phone/Fax

Practice location:
  • Phone: 708-898-0811
  • Fax: 708-898-1839
Mailing address:
  • Phone: 815-714-7171
  • Fax: 815-435-5080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number10178075A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036142380
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: