Provider Demographics
NPI:1790860872
Name:QAYYUM, IMRAN (MD)
Entity type:Individual
Prefix:DR
First Name:IMRAN
Middle Name:
Last Name:QAYYUM
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:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:BRYN MAWR HOSPITAL
Practice Address - Street 2:130 S. BRYN MAWR AVE.
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3121
Practice Address - Country:US
Practice Address - Phone:610-526-4261
Practice Address - Fax:610-526-4661
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD059580L2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1163051Medicaid
NJ8223301Medicaid
PA001805785Medicaid
H17049Medicare UPIN
NJ8223301Medicaid