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1891722385

NPI Code Detail

MEDICARE: MR. HUSSAIN S IMAM MD

MEDICARE: MR. HUSSAIN S IMAM MD

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	ME81517	FL

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891722385
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HUSSAIN S IMAM MD

Provider Business Mailing Address
First Line	:	4205 BELFORT RD STE 4015
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-3623
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10058 BAYMEADOWS RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-7177
Country	:	US
Telephone Number	:	904-636-5400
Fax Number	:	904-928-0654

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	11/22/2019

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Directions to “ MR. HUSSAIN S IMAM MD” Practice Location

Language	Start Address	Practice Location

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