Provider Demographics
NPI:1093811374
Name:AHMAD, TANVEER (MD)
Entity Type:Individual
Prefix:
First Name:TANVEER
Middle Name:
Last Name:AHMAD
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:PO BOX 1527
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-1527
Mailing Address - Country:US
Mailing Address - Phone:815-338-0900
Mailing Address - Fax:815-338-5390
Practice Address - Street 1:21807 W GRANT HWY
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IL
Practice Address - Zip Code:60152-2944
Practice Address - Country:US
Practice Address - Phone:815-568-1074
Practice Address - Fax:815-568-0134
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072630207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072630Medicaid
IL05600319OtherBCBS
ILIL5952Medicare PIN
IL05600319OtherBCBS
IL036072630Medicaid