Provider Demographics
NPI:1124602230
Name:AHMED, SYED IJLAL
Entity Type:Individual
Prefix:
First Name:SYED IJLAL
Middle Name:
Last Name:AHMED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 SOUTH SPRING AVENUE
Mailing Address - Street 2:SLU CARE ACADEMIC PAVILION, 3RD FLOOR
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110
Mailing Address - Country:US
Mailing Address - Phone:314-977-6082
Mailing Address - Fax:314-977-6086
Practice Address - Street 1:1225 SOUTH GRAND BLVD
Practice Address - Street 2:SLUCARE CENTER FOR SPECIALIZED MEDICINE
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104
Practice Address - Country:US
Practice Address - Phone:314-977-6082
Practice Address - Fax:314-977-6086
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2022-05-17
Deactivation Date:2022-03-22
Deactivation Code:
Reactivation Date:2022-05-17
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2021020578390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program