=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487076766
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIRZA R BAIG
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2014
-----------------------------------------------------
Last Update Date | 01/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1519 W GRANVILLE AVE APT 1B
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60660-1811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-690-2589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1519 W GRANVILLE AVE APT 1B
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60660-1811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-690-2589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172A00000X
-----------------------------------------------------
Taxonomy Name | Driver
-----------------------------------------------------
License Number | B20055679313
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------