MEDICARE: DR. AHMAD H AHMAD M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	030108732	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05832029	OTHER	IL	BLUE CROSS/BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	113690990	OTHER	ID	FED TAX ID #
4	612624	OTHER	IL	HEALTHLINK

General Provider Information

NPI Number	:	1053397018
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AHMAD H AHMAD M.D.

Provider Business Mailing Address
First Line	:	1770 E LAKE SHORE DR
Second Line	:	SUITE 201
City	:	DECATUR
State	:	IL
Zip	:	62521-3832
Country	:	US
Telephone Number	:	217-428-7921
Fax Number	:	217-428-7931

Provider Business Practice Location Address
First Line	:	1770 E LAKE SHORE DR
Second Line	:	SUITE 201
City	:	DECATUR
State	:	IL
Zip	:	62521-3832
Country	:	US
Telephone Number	:	217-428-7921
Fax Number	:	217-428-7931

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	07/19/2010

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