Provider Demographics
NPI:1114591393
Name:TAHIR SIDDIQ
Entity Type:Organization
Organization Name:TAHIR SIDDIQ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAHIR
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-530-4932
Mailing Address - Street 1:441 CHASEWAY DR
Mailing Address - Street 2:
Mailing Address - City:PIKE ROAD
Mailing Address - State:AL
Mailing Address - Zip Code:36064-3312
Mailing Address - Country:US
Mailing Address - Phone:469-530-4932
Mailing Address - Fax:
Practice Address - Street 1:441 CHASEWAY DR
Practice Address - Street 2:
Practice Address - City:PIKE ROAD
Practice Address - State:AL
Practice Address - Zip Code:36064-3312
Practice Address - Country:US
Practice Address - Phone:334-396-0201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care