Healthcare Provider Details

I. General information

NPI: 1578686762
Provider Name (Legal Business Name): SIRAJ SIDDIQI M.D PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 COMMERCE PKWY
LAGRANGE KY
40031-8779
US

IV. Provider business mailing address

1019 COMMERCE PKWY
LAGRANGE KY
40031-8779
US

V. Phone/Fax

Practice location:
  • Phone: 502-225-9098
  • Fax: 502-225-9851
Mailing address:
  • Phone: 502-225-9098
  • Fax: 502-225-9851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number28062
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. SIRAJ U SIDDIQI
Title or Position: OWNER
Credential: M.D.
Phone: 502-225-9098