Provider Demographics
NPI:1245224724
Name:ALZEIDAN, FADI I (MD)
Entity Type:Individual
Prefix:
First Name:FADI
Middle Name:I
Last Name:ALZEIDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 E 86TH AVE
Mailing Address - Street 2:PO BOX 10645
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6382
Mailing Address - Country:US
Mailing Address - Phone:219-769-1670
Mailing Address - Fax:219-738-6714
Practice Address - Street 1:7863 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5553
Practice Address - Country:US
Practice Address - Phone:219-769-6639
Practice Address - Fax:219-769-0636
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200300510Medicaid
IN237730GMedicare PIN
IN231940AMedicare ID - Type Unspecified
IN200300510Medicaid