MEDICARE: UNKNOWN IMTIYAZ PASHA

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	291U00000X	Clinical Medical Laboratory		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14D2557061	OTHER	IL	LICENSE

General Provider Information

NPI Number	:	1962141895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	UNKNOWN IMTIYAZ PASHA

Provider Business Mailing Address
First Line	:	6759 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-3220
Country	:	US
Telephone Number	:	773-432-7187
Fax Number	:

Provider Business Practice Location Address
First Line	:	4539 N SHERIDAN RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5618
Country	:	US
Telephone Number	:	773-432-7187
Fax Number	:

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

Provider Enumeration Date	:	05/31/2022
Last Update Date	:	08/26/2022

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