Healthcare Provider Details

I. General information

NPI: 1114183290
Provider Name (Legal Business Name): SYED ABUTALIB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W OKLAHOMA AVE
MILWAUKEE WI
53215-4330
US

IV. Provider business mailing address

2361 PAYSPHERE CIR
CHICAGO IL
60674-0023
US

V. Phone/Fax

Practice location:
  • Phone: 414-649-6380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number036118492
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number101070
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: