=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164644886
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SYED M Z A SIDDIQI MD PC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 07/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 93 HICKORY DR
-----------------------------------------------------
City | BECKLEY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25801-2834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-255-9278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 93 HICKORY DR
-----------------------------------------------------
City | BECKLEY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25801-2834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-255-9278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SYED MZA SIDDIQI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 304-255-9278
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 11832
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------