# MAMANATANDATHERNIZAMPC.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1104134915
- **Authorized official:** DR. MAIMANAT NIZAM MD. (PHYSICIAN)
- **Authorized official phone:** (630) 654-1021

## Contact information

- **Practice address:** 2001 W.69THST., CHICAGO, IL 60636
- **Practice address phone:** (773) 778-2355
- **Practice address fax:** (773) 788-2355
- **Mailing address:** 401 TAMERTON PKWY, BURR RIDGE, IL 60527-6347
- **Mailing address phone:** (630) 654-1021
- **Mailing address fax:** (773) 788-2355

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QC1500X | Community Health Clinic/Center | 036-06-9635 | IL | Yes |

## Other

- **Enumeration date:** 09/15/2010
- **Last updated:** 09/15/2010