Provider Demographics
NPI:1114127800
Name:MISBAH UDDIN AHMED MD SC
Entity Type:Organization
Organization Name:MISBAH UDDIN AHMED MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MISBAH
Authorized Official - Middle Name:UDDIN
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-935-2525
Mailing Address - Street 1:555 W COURT ST
Mailing Address - Street 2:STE 200
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3674
Mailing Address - Country:US
Mailing Address - Phone:815-935-2525
Mailing Address - Fax:815-935-1010
Practice Address - Street 1:555 W COURT ST
Practice Address - Street 2:STE 200
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3664
Practice Address - Country:US
Practice Address - Phone:815-935-2525
Practice Address - Fax:815-935-1010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1306854203OtherINDIVIDUAL NPI
IL036205509Medicaid
ILCG4030OtherRAILROAD MEDICARE GROUP
IL110197518OtherRAILROAD MEDICARE
IL036098582Medicaid
IL1922117811OtherINDIVIDUAL NPI
IL930068554OtherRAILROAD MEDICARE
IL036205509Medicaid
IL110197518OtherRAILROAD MEDICARE
IL651320Medicare PIN
IL1922117811OtherINDIVIDUAL NPI