Provider Demographics
NPI:1962683359
Name:FAIRVIEW OGDEN MEDICAL GROUP LTD.
Entity Type:Organization
Organization Name:FAIRVIEW OGDEN MEDICAL GROUP LTD.
Other - Org Name:FAIRVIEW OGDEN MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ZAINULABUDDIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SYED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-968-4790
Mailing Address - Street 1:4121 FAIRVIEW AVE
Mailing Address - Street 2:SUITE # 100
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-2264
Mailing Address - Country:US
Mailing Address - Phone:630-968-4790
Mailing Address - Fax:630-968-8755
Practice Address - Street 1:4121 FAIRVIEW AVE
Practice Address - Street 2:SUITE # 100
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2264
Practice Address - Country:US
Practice Address - Phone:630-968-4790
Practice Address - Fax:630-968-8755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-091132207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091132Medicaid
1609876424OtherINDIVIDUAL NPI
IL036091132Medicaid
1609876424OtherINDIVIDUAL NPI