Healthcare Provider Details

I. General information

NPI: 1669666731
Provider Name (Legal Business Name): SALAM SYED M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2007
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N MAIN ST STE 103
DEFOREST WI
53532-1163
US

IV. Provider business mailing address

210 N MAIN ST STE 102
DEFOREST WI
53532-1163
US

V. Phone/Fax

Practice location:
  • Phone: 414-873-9800
  • Fax:
Mailing address:
  • Phone: 414-873-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number53833
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number53833
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: