Healthcare Provider Details

I. General information

NPI: 1477786598
Provider Name (Legal Business Name): FAWAZ AHMAD MD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 BROADWAY
SEATTLE WA
98122-4379
US

IV. Provider business mailing address

4201 W MEDICAL CENTER DR
MCHENRY IL
60050-8409
US

V. Phone/Fax

Practice location:
  • Phone: 206-215-2520
  • Fax: 206-215-6364
Mailing address:
  • Phone: 815-759-4530
  • Fax: 815-759-8053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD61218892
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036130260
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: