Provider Demographics
NPI:1811004542
Name:FAHEEM, AMJAD MOHAMMED (MD)
Entity Type:Individual
Prefix:
First Name:AMJAD
Middle Name:MOHAMMED
Last Name:FAHEEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:AMJAD
Other - Middle Name:MOHAMMED
Other - Last Name:FAHEEMUDDIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:800 W LINCOLN TRAIL BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-2671
Mailing Address - Country:US
Mailing Address - Phone:270-769-0892
Mailing Address - Fax:270-769-1857
Practice Address - Street 1:914 N DIXIE AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2520
Practice Address - Country:US
Practice Address - Phone:270-769-0892
Practice Address - Fax:270-769-1857
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25792207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1055555OtherELIZABETHTOWN PROV #
KY1055557OtherRADCLIFF PP PROV #
KY108814OtherBLACK LUNG PROV #
KY4359912OtherAETNA PROVIDER #
KY65937476Medicaid
KY000000041595OtherANTHEM PROVIDER #
KY65937468Medicaid
KY00000041594OtherRC ANTHEM PROV #
KY1055554OtherHVILLE PP OFFICE #
KY1055553OtherRCLIFF PP OFFICE #
KY1055556OtherHODGENVILLE PROV #
KY64257926Medicaid
KY65937492Medicaid
KY000000041593OtherHV ANTHEM PROV #
KY1055519OtherETOWN OFFICE PP #
KY1354160OtherMAIL HANDLERS ET #
KY1055519OtherETOWN OFFICE PP #
KY1055553OtherRCLIFF PP OFFICE #
KY0562001Medicare ID - Type UnspecifiedRADCLIFF LOCATION