Provider Demographics
NPI:1134306764
Name:MQISLAM MD LLC
Entity Type:Organization
Organization Name:MQISLAM MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:
Authorized Official - Last Name:ISLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-439-2662
Mailing Address - Street 1:1908 N MAIN ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-2505
Mailing Address - Country:US
Mailing Address - Phone:606-439-2662
Mailing Address - Fax:606-439-0612
Practice Address - Street 1:1908 N MAIN ST
Practice Address - Street 2:SUITE 230
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-2505
Practice Address - Country:US
Practice Address - Phone:606-439-2662
Practice Address - Fax:606-439-0612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36373207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPENDINGMedicare PIN