Provider Demographics
NPI:1427033828
Name:ALAM, FAKHRE (MD)
Entity Type:Individual
Prefix:
First Name:FAKHRE
Middle Name:
Last Name:ALAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:FAKHRE
Other - Middle Name:
Other - Last Name:ALAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903
Mailing Address - Country:US
Mailing Address - Phone:618-549-6378
Mailing Address - Fax:618-529-2347
Practice Address - Street 1:2731 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1027
Practice Address - Country:US
Practice Address - Phone:618-549-6378
Practice Address - Fax:618-529-2347
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361017042084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101704Medicaid
130023524OtherRR MEDICARE
IL704790Medicaid
IL036-101704OtherILLINOIS LICENSE NUMBER
P00183581Medicare PIN
IL036101704Medicaid
210516Medicare PIN