MEDICARE: DR. NOOR TAZUDEEN 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	207N00000X	Dermatology Physician	5930-851	WI
2	207R00000X	Internal Medicine Physician	125065910	IL
3	207N00000X	Dermatology Physician	036.146214	IL
4	207N00000X	Dermatology Physician	01084857A	IN

General Provider Information

NPI Number	:	1366857286
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NOOR TAZUDEEN M.D.

Provider Business Mailing Address
First Line	:	4700 N MARINE DR STE 220
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-7972
Country	:	US
Telephone Number	:	608-287-2658
Fax Number	:	773-334-3399

Provider Business Practice Location Address
First Line	:	4700 N MARINE DR STE 220
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-7972
Country	:	US
Telephone Number	:	608-287-2658
Fax Number	:

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

Provider Enumeration Date	:	06/30/2014
Last Update Date	:	11/06/2020

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