Provider Demographics
NPI:1073651808
Name:ANSARI, NADEEM (MD)
Entity Type:Individual
Prefix:
First Name:NADEEM
Middle Name:
Last Name:ANSARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 RIVERSIDE DR STE 2100
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-5004
Mailing Address - Country:US
Mailing Address - Phone:815-935-2784
Mailing Address - Fax:815-935-5687
Practice Address - Street 1:400 RIVERSIDE DR STE 2100
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-5004
Practice Address - Country:US
Practice Address - Phone:815-935-2784
Practice Address - Fax:815-935-5687
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-071794207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071794Medicaid
IL036-071794OtherLICENSE NUMBER