Provider Demographics
NPI:1891238077
Name:IMDAD LONG TERM CARE, LLC
Entity Type:Organization
Organization Name:IMDAD LONG TERM CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RIFFAT
Authorized Official - Middle Name:Y
Authorized Official - Last Name:IMDAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-651-6129
Mailing Address - Street 1:424 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1378
Mailing Address - Country:US
Mailing Address - Phone:618-939-1193
Mailing Address - Fax:618-939-7539
Practice Address - Street 1:18 LOCHHAVEN LN
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-8020
Practice Address - Country:US
Practice Address - Phone:636-527-9595
Practice Address - Fax:636-527-9595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000160629207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty