=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598460982
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KUMAIL ABBAS HAIDER DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2023
-----------------------------------------------------
Last Update Date | 08/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1969 W OGDEN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-3765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-864-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1950 W POLK ST # 6150
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-3723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-948-5011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 125.082081
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------