=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871767111
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KHAJA ALIUDDIN MD SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2008
-----------------------------------------------------
Last Update Date | 04/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3147 W CERMAK RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60623-3307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-522-1216
-----------------------------------------------------
Fax | 773-522-9660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3147 W CERMAK RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60623-3307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-522-1216
-----------------------------------------------------
Fax | 773-522-9660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/PRESIDENT
-----------------------------------------------------
Name | DR. KHAJA ALIUDDIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 773-522-1216
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------