Provider Demographics
NPI:1245573542
Name:IMAM, BASEL (MD)
Entity type:Individual
Prefix:
First Name:BASEL
Middle Name:
Last Name:IMAM
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 1:100 SPALDING DR STE 406
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6554
Mailing Address - Country:US
Mailing Address - Phone:630-961-9485
Mailing Address - Fax:
Practice Address - Street 1:100 SPALDING DR STE 406
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6554
Practice Address - Country:US
Practice Address - Phone:630-961-9485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI82607-20207V00000X
AZ000000207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1245573542Medicaid