Healthcare Provider Details

I. General information

NPI: 1114919404
Provider Name (Legal Business Name): EHSAN QADIR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 12/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 WALLACE AVE.
LEITCHFIELD KY
42754-2414
US

IV. Provider business mailing address

910 WALLACE AVE
LEITCHFIELD KY
42754-2414
US

V. Phone/Fax

Practice location:
  • Phone: 270-259-1656
  • Fax: 270-259-9536
Mailing address:
  • Phone: 270-259-1656
  • Fax: 270-259-9536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number33703
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number33703
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: