MEDICARE: MAIMANAT NIZAM 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	207QA0505X	Adult Medicine Physician	036-069635	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265579262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAIMANAT NIZAM M.D.

Provider Business Mailing Address
First Line	:	401 TAMERTON PKWY
Second Line	:
City	:	BURR RIDGE
State	:	IL
Zip	:	60527-6347
Country	:	US
Telephone Number	:	630-654-1021
Fax Number	:

Provider Business Practice Location Address
First Line	:	2001 W 69TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60636-3262
Country	:	US
Telephone Number	:	773-778-2355
Fax Number	:	773-778-2355

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

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	06/13/2013

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