Provider Demographics
NPI:1225587108
Name:JAVED ILYAS SIDDIQI, M.D. LLC
Entity Type:Organization
Organization Name:JAVED ILYAS SIDDIQI, M.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-244-0019
Mailing Address - Street 1:380 MERRIMACK ST
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-5870
Mailing Address - Country:US
Mailing Address - Phone:978-689-0033
Mailing Address - Fax:978-682-0033
Practice Address - Street 1:380 MERRIMACK ST
Practice Address - Street 2:SUITE 2C
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-5870
Practice Address - Country:US
Practice Address - Phone:978-689-0033
Practice Address - Fax:978-682-0033
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JAVED I SIDDIQI, M.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA56836207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110043613AMedicaid
MAA58684Medicare UPIN
MA110043613AMedicaid