Provider Demographics
NPI:1235455619
Name:IMAM, SYED FAHAD (MD)
Entity Type:Individual
Prefix:
First Name:SYED
Middle Name:FAHAD
Last Name:IMAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:420 NE GLEN OAK AVE STE 401
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3112
Mailing Address - Country:US
Mailing Address - Phone:309-676-8123
Mailing Address - Fax:309-676-8455
Practice Address - Street 1:765 N KELLOGG ST STE 203
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2859
Practice Address - Country:US
Practice Address - Phone:309-676-8123
Practice Address - Fax:309-676-8455
Is Sole Proprietor?:No
Enumeration Date:2010-04-11
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-142852207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036142852Medicaid