Provider Demographics
NPI:1912237017
Name:TAREK KUDAIMI MD, LLC
Entity Type:Organization
Organization Name:TAREK KUDAIMI MD, LLC
Other - Org Name:TAREK KUDAIMI MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAREK
Authorized Official - Middle Name:
Authorized Official - Last Name:KUDAIMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-836-1310
Mailing Address - Street 1:801 MACARTHUR BLVD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2915
Mailing Address - Country:US
Mailing Address - Phone:219-836-1310
Mailing Address - Fax:219-836-0617
Practice Address - Street 1:801 MACARTHUR BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2915
Practice Address - Country:US
Practice Address - Phone:219-836-1310
Practice Address - Fax:219-836-0617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044239207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL90000885OtherBLUE CROSS BLUE SHIELD ILLINOIS
IN200191040BMedicaid
IN3200450OtherUNITED HEALTH CARE
IN110182794OtherRAILROAD MEDICARE
IN000000095728OtherANTHEM
IN237151OtherWELLCARE
IN1689638033Medicare NSC
ING87574Medicare UPIN
IN237151OtherWELLCARE