=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700803541
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | QAMARUDDIN QAZI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2006
-----------------------------------------------------
Last Update Date | 11/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2845 GREENBRIER RD 1ST FLOOR
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54311-6519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-288-8100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3720 DEER RUN CT
-----------------------------------------------------
City | MANITOWOC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54220-1668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-684-8939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | 38877
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------