Healthcare Provider Details

I. General information

NPI: 1922448315
Provider Name (Legal Business Name): TAZEEN FATIMA AL-HAQ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 11/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 4TH ST
SPRINGFIELD IL
62702-5238
US

IV. Provider business mailing address

1504 SEVEN PINES RD APT. H
SPRINGFIELD IL
62704-5796
US

V. Phone/Fax

Practice location:
  • Phone: 217-757-8100
  • Fax: 217-757-8161
Mailing address:
  • Phone: 217-220-6126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.063576
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number60144
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: