Provider Demographics
NPI:1669666731
Name:SYED, SALAM (MD)
Entity Type:Individual
Prefix:
First Name:SALAM
Middle Name:
Last Name:SYED
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 1:210 N MAIN ST
Mailing Address - Street 2:STE 102
Mailing Address - City:DEFOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532-1163
Mailing Address - Country:US
Mailing Address - Phone:414-873-9800
Mailing Address - Fax:
Practice Address - Street 1:210 N MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:DEFOREST
Practice Address - State:WI
Practice Address - Zip Code:53532-1163
Practice Address - Country:US
Practice Address - Phone:414-873-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53833208D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1669666731Medicaid