Organization
MAMANATANDATHERNIZAMPC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MAIMANAT NIZAM MD. (PHYSICIAN)
(630) 654-1021
Entity
Organization
Contact information
Practice address
2001 W.69THST., CHICAGO, IL 60636
(773) 778-2355
(773) 788-2355
Mailing address
401 TAMERTON PKWY, BURR RIDGE, IL 60527-6347
(630) 654-1021
(773) 788-2355
Taxonomy
Speciality
Code
Description
License number
State
261QC1500X
Community Health Clinic/Center
Primary
036-06-9635
IL
Other
Enumeration date
09/15/2010
Last updated
09/15/2010
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