=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679534952
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OMER QUREISHY MBBS.MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 BRUCE STREET
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-537-9300
-----------------------------------------------------
Fax | 507-537-9356
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14348 FLORA WAY
-----------------------------------------------------
City | APPLE VALLEY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55124-3336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-953-3631
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 48196
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------