Healthcare Provider Details

I. General information

NPI: 1821048513
Provider Name (Legal Business Name): SUHAIL I HAQUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 S ROY WILKINS AVE
LOUISVILLE KY
40203-2072
US

IV. Provider business mailing address

720 W BROADWAY STE 202
LOUISVILLE KY
40202-3245
US

V. Phone/Fax

Practice location:
  • Phone: 502-561-0520
  • Fax: 502-561-0521
Mailing address:
  • Phone: 502-561-0943
  • Fax: 502-561-0944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number35219
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number01047434A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number35219
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35219
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: