Provider Demographics
NPI:1821007543
Name:ALZEIDAN MEDICAL CORPORATION, PC
Entity Type:Organization
Organization Name:ALZEIDAN MEDICAL CORPORATION, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FADI
Authorized Official - Middle Name:
Authorized Official - Last Name:ALZEIDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-769-6639
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN231940Medicare ID - Type Unspecified